Your Name*

Date of Birth*

Your Email*

Date of Appointment*

Artists Name

Area to be tattooed*

Tattoo Details

Do you currently suffer or have you ever suffered from the following:-

Heart diseaseHigh blood pressureLow blood pressureAsthmaEpilepsy/seizuresHaemophilia/blood clotting disordersSkin complaints (psoriasis/eczema for example)Keloid ScarsDiabeticHIVHaemorrhagingAre you prone to fainting/panic attacks?Do you regularly take blood thinning medication?Any other relevant health issues?

If you have selected any of the above please give details here:-

Please provide any details of any associated problems which may prevent you from getting tattooed:-

Are you breast feeding

NoYes

Covid-19 Declaration

I confirm that I have not tested positive for COVID-19 in the last 48 hours.*

I confirm that I have not been in contact with anyone who has tested positive for COVID-19 in the last 48 hours.*

I confirm that I am not experiencing any symptoms related to COVID-19 in the last 48 hours.*

I declare that all of the information provide is correct to the best of my knowledge!

After consulting with my artist I am happy to proceed with my desired tattoo today.

I will agree and adhere to aftercare advice given and am aware that improper care of my tattoo can result in infection.

Signed*

Date*

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