Legal Name *

The name on your legal documents.

First Name

Last Name

Phone *

(###)

###

####

Allergies (metals, food, latex, soaps, adhesives, etc.) *

Yes

No

Heart Condition(s) *

Yes

No

Hemophilia *

Yes

No

Anemia *

Yes

No

Hepatitis (A, B, C, D) *

Yes

No

Autoimmune Disease or Disorder? *

Yes

No

Diabetes *

Yes

No

Epilepsy *

Yes

No

Skin Conditions ( Eczema, Rosacea, Psoriasis, Sensitivity, etc) *

Yes

No

Hypertrophic Scarring (Keloids) *

Yes

No

Any mental impairment or disability which might affect your judgement on the decision to have a tattoo done at this time? *

Yes

No

Pregnant/Nursing (Breastfeeding) *

Yes

No

Taking blood thinners such as Aspirin, Ibuprofen, etc. *

Yes

No

Service Agreement Digital Signature *

I have read and agree to all the terms and conditions presented above.