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Consent & Release Form

Artist Name*

Your full legal name*

Present Date*

Month

Day

Year

Email*

Phone*

This form prefers the +614 version.

Birthday*

Month

Day

Year

I have eaten in the last 2-4 hours.

I have not concumed alcohol in the last 24 hours.

Last consumed if under 24 hours

I am not pregnant and/or breastfeeding.

I am at least 18 years or older.

I am clear of HIV, hepatitis A, B, C or any other blood pathogens.

Do you suffer from any heart conditions?*

Yes (which will be alerted to the artist)

No

Are you diabetic? *

Yes (which will be alerted to the artist)

No

Do you suffer with any form of seizure causing condition?*

Yes (which will be alerted to the artist)

No

Do you have any blood clotting disorders?*

Yes (which will be alerted to the artist)

No

Do you suffer from any condition that will or may compromise your immune system?*

Yes (which will be alerted to the artist)

No

Please describe your conditions for the above 'Yes' answers.

I understand this procedure concluding to permanent modification procedure(s) will be conducted by a self employed artist.

I acknowledge and understand the correct healing instructions given to me by the artist and will apply them accordingly.

I acknowledge that this tattoo is a permenent decision and change on my body that may fade, change colour and clarity as it ages over a long period of time.

Are you prone to dizziness and/or fainting?*

Have you recently been exposed to Covid-19 which may conclude you to be a carrier of the virus?*

Known allergies

Photo I.D*

Signature

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