Name *

First Name

Last Name

Birthdate *

You must be at least 18 years of age to be tattooed in our shop

MM

DD

YYYY

Phone *

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Inform your artists of any medical or skin conditions that you may have in the boxes below. If there are any other medical conditions you don't wish to state on this form, please do so verbally with your artist. This information is STRICTLY confidential between you and your artist and ensures everyone's safety in the tattoo process.

Accutane/Acne/Skin Medications

Allergies ( latex, soap, fragrance, ect.)

Blood Thinning Medication

Cold Sores/ Fever Blisters

Diabetes

Eczema

Epilepsy

Heart Conditions

Hemophilia

Prone to Passing Out/Fainting

Psoriasis

Reaction to Tattoo Pigment

Reaction to aftercare Second Skin/bandaging

Any other issue that you would like to discuss privately with your artist

Date *

MM

DD

YYYY