Consent Form

Select Studio *

Name of Operator

Name of Client

Client Address

Contact No.

Email Address *

Date of Birth *

Form of ID Used *

Site of Tattoo / Piercing

For Clients Information

Known potential risks associated with tattooing/piercing:

Medical Conditions

Eczema, Psoriasis, Acne, Cellulitis or other skin conditions

Yes
No

Heart disorders - more prone to serious heart complications from any blood infections

Yes
No

High/Low blood pressure - can cause light headedness

Yes
No

Haemophilia and other bleeding disorders - May result in poor clotting / healing

Yes
No

Epilepsy and other forms of seizures - Medication may cause side affects and may result in fitting during treatment

Yes
No

Diabetes - Can reduce healing properties of the skin resulting in infection

Yes
No

Hepatitis - May post a risk for the operator

Yes
No

Autoimmune Diseas or treatment causing it e.g. Cancer Treatment - more prone to serious infection, HIV a risk for the operator

Yes
No

Pregnant - Immunse response affected by pregnancy and any infection may harm the unborn child

Yes
No

Nursing mother - risk of infection, can be a risk to the baby

Yes
No

Medication - Side affects may affect healing and recovery from treatment

Yes
No

Any other condition not listed - listed below if yes

Yes
No

Please note some of the treatment cannot be undertaken if you are under the influence of drugs or alcohol. I confirm that I have read the above information and discussed it with my operator.

I Agree

Individual Consent

I Agree

I acknowledge by signing this agreement that I have been given the full opportunity to ask any questions which I might have about obtaining a tattoo/piercing and that all of my questions have been answered to my satisfaction.

I acknowledge that this is not reasonable possibly to determine whether I might have an allergic reaction to the pigments, jewellery or the process used in my tattoo/piercing and I agree to accept that such risk is possible. I acknowledge that there may be a risk associated with the ink products used in tattooing and that such ink products may contain substances that are harmful to my health.
I understand that discrepancies in colour between the final design and final tattoo can occur due to skin types and aftercare of the tattoo.
I declare I give my full consent to the tattoo/piercing being carried out by the aforementioned practitioner. I confirm that potential complications e.g.infection and swelling for the procedure undertaken, and aftercare instructions have been explained to me. Written aftercare advice sheet containing more detailed information has been given to me and I agree that it is my responsibility to read this and follow the instructions on it until the site has healed.
I confirm that the above information provided by me for this consent form is correct to the best of my knowledge, that I am over the age of consent for this procedure (i,e 18 years old for tattoos) and I a NOT currently under the influence of alcohol or drugs.

Name of Client

Today's Date *

Artist Name

Today's Date *

Please complete the consent form below.

Medical Conditions

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