Dreadmoor Tattoo

Consent & Waiver Form

First name

Last name

Birthday

Month

Day

Year

(IF CLIENT IS UNDER 18, The following Must be completed by parent or legal guardian) ----- Parent/Guardian Name

Primary Phone

Primary Email

Parent/Guardian Phone Number

Valid Government - Issued ID?

Yes

No

Current Address

Address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Risk Notification

Please Read Carefully and Acknowledge each item

I understand that body art procedures can cause allergic reactions, bleeding, bruising, pain, swelling, and irreversible modifications to the body.

I acknowledge

I understand that body art procedures increase the risk of infection.

I Acknowledge

I understand that individuals with heart conditions are at greater risk of bacterial endocarditis and should consult a physician before proceeding.

I acknowledge

Client Health Evaluation

Please answer the following questions below.

Are you 18 years of age or older?

Yes

No

Have you eaten within the past four hours?

Yes

No

Are you under the influence of drugs or alcohol?

Yes

No

Have you taken blood thinners, NSAIDS, or any medications that may affect healing?

Yes

No

Do you have allergies to dyes, pigments, latex, iodine, or similar products?

Yes

No

Do you have Hemophilia, Seizures, narcolepsy, or other conditions affecting procedures?

Yes

No

Do you have any skin diseases, sensitivities, or reactions to soaps/disinfectants?

Yes

No

Do you have any communicable diseases ( Hepatitis, HIV, etc.)?

Yes

No

Do you have diabetes, high blood pressure, heart disease, or any healing impairments?

Yes

No

Are you or have you been pregnant within the last 3 months?

Yes

No

If you have medical concerns have you consulted your physician before receiving body art?

Yes

No

Informed Consent Statement

By signing below, I confirm:

I am voluntarily obtaining this tattoo or piercing procedure of my own free will.
I have read and understand the risks and health screening questions above.
I have had the opportunity to ask questions before, during, and after the procedure.
I have recieved both written and verbal aftercare instructions.
I understand that the artist will maintain a record of this procedure.

Signature of Client

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