Waiver & Consent Form

What type of procedure(s) are you asking Inkaholicz to perform?

Tattoo

Piercing

Other

Will the appointment be for you or someone for whom you are legally responsible?

I will be the client participating in the tattoo session

I am the legal parent/custodian/guardian of a minor client participating in the tattoo session

First Name of Client

Last name of Client

Have you already scheduled an appointment?

Are you at least 18 years of age?

Clients must be at least 18 years of age or have a consenting adult complete this form.

Date of Birth

Month

Day

Year

Driver's License

File upload

Please submit a photo of the front of your drivers license or state identification card.

The following questions pertain to the Client's health & medical background information that will be relevant to the appointment.

Have you been hospitalized in the last 12 months?

Yes

No

Are you suffering from a medical condition, illness, or injury?

Yes

No

Examples: diabetes, epilepsy, hemophilia, HIV/AIDS, any communicable disease, heart condition, pregnancy, nursing, blood-thinning medication, or impairment from alcohol or drugs.

Do you have any skin conditions?

Yes

No

I declare that the information provided above is accurate and complete.