Your Name *

First Name

Last Name

Phone

(###)

###

####

D.O.B. *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How did you hear about me?

Instagram

Facebook

Friend

Google Search

Other

Have you eaten in the last 2 hours? *

Yes

No

Do you have HEPATITIS A, B, or C? *

Yes

No

Do you have HIV/AIDS? *

Yes

No

Do you have any known allergies? *

Yes

No

Do you have diabetes?

Yes

No

Do you have difficulty with blood clotting? *

Yes

No

Do you have any heart-related problems? *

Yes

No

Do you have high blood pressure? *

Yes

No

Have you taken any anticoagulants (aspirin, ibuprofen, etc) in the last 24 hours? *

Yes

No

Are you currently pregnant or breastfeeding? *

Yes

No

Agreement & Consent *

I confirm that all personal and medical information provided above is accurate and complete. I understand that withholding any information may result in complications during or after the procedure.

I understand that tattooing is a permanent procedure and carries inherent risks including but not limited to: infection, scarring, allergic reactions to pigments, and swelling. I accept these risks and choose to proceed with the procedure.

I agree to follow all aftercare instructions provided by the artist. I understand that failing to follow these instructions may result in complications, and I accept full responsibility for my aftercare.

I confirm that I am not under the influence of alcohol, drugs, or any substances that could impair my judgment. I am of legal age (18+) and am making this decision of my own free will.

I grant permission for photographs of my tattoo to be taken and used for portfolio purposes, including social media and website display.

I understand that all services are non-refundable and that the final appearance of my tattoo may vary from the design discussed.