Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone Number
*
Date of Birth
*
MM
DD
YYYY
Name of tattoo artist:
*
Do you have any skin conditions that are currently affecting your skin, or will affect the healing of your tattoo? (eg. acne, keloid/excessive scarring, psoriasis, sunburn, etc.)
Do you have a latex allergy?
Do you have any communicable infections or disorders (eg. HIV/AIDS, hepatitis B/C, MRSA, etc.)
Do you have any infections or disorders that may affect your ability to be tattooed or heal from a tattoo (eg. diabetes, epilepsy, severe anxiety, fear of needles or blood, etc.)
*
Signature
*
Date
*
MM
DD
YYYY
