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First Name
Date of Birth
Phone
Select your Artist
Last Name
Address
Email Address
Location of tattoo
Description of your tattoo
Are you under the influence of drugs or alcohol?
*
Yes
No
Do you have a communicable deisease?
*
Yes
No
Are you pregnant or nursing?
*
Yes
No
Do you have any skin conditions?
*
Yes
No
SKIN CONDITIONS (e.g. Rashes, Eczema, Infection, Psoriasis, Freckles, Boils, Pimples, Sunburn, etc. If YES please list them all)
Do you have any conditions that may STOP a procedure such as immune-comprimised, hemophilia, skin disease, and blood thinners (Medication)? If YES, please explain
Please tell us about your medical history (e.g. Diabetes, Cardiovascular Disease, Epilepsy, Blood-related disease etc.)
Do you have any allergies to dyes, disinfectants, soaps, metals, pigments, and latex? If YES, please list them all.
Acknowledgment and Waiver
I understand that this procedure is a permanent change to my skin and body
I allow my tattoo to be photographed and be used for tattoo shop portfolio and social media
I acknowledge that the tattoo shop does not offer refunds
I understand that the studio does not have a way of identifying if I am allergic to the elements or ingredients that will be used for my tattoo.
I understand that i need to take care of the tattoo by following the instructions given to me by the tattoo shop
I understand that i might get an infection if I don't follow the instructions given to me in regards of taking good care of my tatoo
I agree to hold harmless the tattoo shop against any claims, expenses, damages, and liabilities
I confim that the information I provided in this document is accurate and true.
Your Signature
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Was Verbal aftercare given?
*
yes
no
ARTIST NAME
LOT #
EXPIRATION DATE
ANOMALINK ART GALLERY
1045 GARDEN OF THE GODS RD STE E COLORADO SPRINGS, CO 809087
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