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Consent Form
First Name
Last Name
Date of Birth (must be over 18 and present a valid ID)
Email
Phone
Location
*Should you have any questions, Concerns or complaints regarding your tattoo procedure received regarding the safety, sanitization, or sterilization process, please contact below: Houston County Health Department-Environmental Health Section 98 Cohen Walker dr., Warner Robins, Ga 31088 (478) 218- 2020
*I acknowledge that by signing this form That I have been given full opportunity to ask any, and all questions which I might have about obtaining a tattoo from Golden Dagger Tattoo Club, and I have been advised of the facts and matter set forth below, and I agree as follows:
Please select any of the following medical or communicable condition that you (client) may have at the time the tattoo procedure is performed.*
Diabetes
History of Hemophilia
Hepatitus A
Hepatitus B
Hepatitus C
History of skin disease, skin leasions, or skin sensitivities to soap, disinfections, etc.
History of allergies or adverse reactions to pigments, dyes, or other skin sensitivities
History/suspicion of adverse reaction to latex or products containing latex
History of Keloid formation
History of epilepsy, seizures, fainting, or narcolepsy
Taking medications such as aspirin or other anticoagulants which thin the blood
In the last three months possibility of pregnancy,nursing or breastfeeding
Under the influence of illegal drugs/alcohol
Over 400lbs So artist can make appropriate accomadations
I understand the health conditions above may increase health risk when receiving a tattoo.
Clear
Client has the ability to ask questions about the procedure.
Clear
Client refuses to disclose the information listed.
Clear
Final Signature
Clear
Today's date
Upload Photo ID
Upload File
Upload supported file (Max 15MB)
Have you eaten in the last 4 hours?
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******For artist use******
Tattoo Description
Estimated Price
Artist Name
Artist License
I am not under the influence of drugs or alcohol
I have provided procedures in writing (Signed by client) Advising them of proper aftercare of a tattoo
Artist Signature
Clear
Send
Thanks for submitting!
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