Tattoo Consent Form – Clarity 11

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Personal Information

Name*

Date of Birth (DD/MM/YYYY)*

Email Address*

Phone*

House Number*

Street*

City*

Post Code*

*I hereby declare I give full consent to

*Of Clarity 11 to tattoo my...

Medical Information

Any heart condition?*
NoYesOther

Haemophilia?*
NoYes

Haemorrhaging / bruise easily?*
NoYes

HIV / HEP A B C D etc?*
NoYes

High blood pressure?*
NoYes

Diabetes?*
NoYes

Reaction to skin care products/moisturisers/soap/creams?*
NoYesOther

Eaten in the last 4 hours?*
NoYes

Slept well in the last 24 hours?*
NoYes

Are you pregnant?*
NoYes

Have you taken any blood thinning medication?*
NoYes

Are you prone to fainting or dizziness?*
NoYes

Have you taken any drugs or consumed alcohol in the past 24 hours?*
NoYes

Consent Agreement

I can confirm that I am not taking any medication or suffering from any illness, condition or allergy, which a reasonable person should be aware of, may react adversely to, or be aggravated by tattooing. I confirm I have been given aftercare in writing and that it has been explained to me and that I can understand it. I also confirm that I will follow the aftercare procedure until the healing process is complete. I understand that there are associated risks with tattooing, which include infection, scarring, allergic reactions and localised swelling. In giving this consent, I release this establishment and it's employees from all liabilities, actions and demands which I may have now or in the future for any loss or damage suffered whatsoever caused as a result of my tattooing (except as a result of fraudulent misstatement or in respect of personal injury caused by our own negligence. We DO NOT disclose personal information to third parties!

I have read and agreed to the terms of service

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Apologies, we cannot tattoo anyone who has HIV. Please return to the homepage.