Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date of your tattoo

MM

DD

YYYY

I affirm that I'm over the age of 18 and can legally consent to receiving this tattoo. *

Yes

No

Do you have any known allergies or adverse reactions to substances such as nitrile, pigments, dyes, disinfectants, metals, adhesives, or other sensitivities related to body art procedures? *

Yes

No

Do you have a history of epilepsy, seizures, fainting, or narcolepsy? *

Yes

No

Are you currently taking any medications or do you have any conditions that may affect blood circulation and/or your ability to fight infection? *

Yes

No

Are you currently pregnant or breastfeeding?

Yes (Unfortunately, we cannot proceed with the tattoo at this time)

No

Have you eaten within the last 4 hours? *

Yes

No

Do you consent to your artist using photos and/or videos of your tattoo for social media, promotional, and portfolio purposes? *

Yes

No

I confirm that I'm consenting to this tattoo of my own free will, without influence from any other person, and without being under the influence of drugs and/or alcohol. *

Yes

No

I understand that receiving a tattoo is a permanent change to my physical appearance.

Yes

No

I acknowledge that tattoo removal may not be possible or may result in scarring. *

Yes

No

I accept all risks and responsibilities associated with the tattoo, including but not limited to infections, blowouts, and reactions during and after the procedure. *

Yes

No

I take full responsibility for the design/text of the tattoo, from the initial design to the final application, including grammar, punctuation, and spelling. *

Yes

No

I agree to follow the aftercare instructions provided by the artist, understanding that failure to do so may lead to negative outcomes for which I'm responsible. *

Yes

No

I understand that certain medications and/or medical conditions may interfere with the tattoo and healing process, potentially increasing complications and healing time. *

Yes

No

I confirm that I'm not experiencing symptoms of illness such as cough, shortness of breath, fever, chills, muscle pain, headache, sore throat, or loss of taste or smell. *

Yes

No

I have read and understood the above statements, and I declare under penalty of perjury that the information provided is accurate. *

Yes

I agree not to make any claims, seek damages, or take legal actions against Nadine arising from or related to my tattoo or the procedure, to the fullest extent permitted by law. *

Yes