Consent Form- Nocturnal Ink Full Legal Name * First Name Last Name Preferred Name First Name Last Name Email * Phone (###) ### #### Are you currently taking any blood thinners? * Yes No Are you currently pregnant or nursing? * Yes No Do you have a history of any of the following medical conditions: Alcoholism Epilepsy Eczema HIV Alopecia Autoimmune Disorder Keloid Scarring Fainting Episodes Liver Disease Blisters/Herpes Simplex Fever MRSA Bleeding Disorders Forehead/Brow Lift Organ Transplant Cancer Face Lift Shingles Chemotherapy/Radiation Haemophilia Skin Conditions Diabetes Heart Condition Dermatitis Easy Bleeding Hepatitis High Blood Pressure Thyroid Issues Tumours,Growths or Cysts * Yes No Do you have any allergies? * Yes No Is this your first tattoo? * Yes No Emergency Contact * First Name Last Name Emergency Contact Phone * (###) ### #### Please list below any prescription or over-the-counter medication you are currently taking A tattoo involves the application of a small design on your skin using sterilized equipment and tattoo ink. The tattoo will be placed in the agreed-upon location on your body. I understand that there may be a certain amount of discomfort or pain associated with this procedure and that other possible adverse side effects may include: minor and temporary bleeding, bruising, redness, or other discoloration and/or swelling. Fading or loss of pigment may occur. Secondary infection in the area of the procedure is rare if properly cared for, but may occasionally occur. By my signature below, I specifically acknowledge that I have been advised of the facts and matters set below, and I agree as follows: Please initial: ____ I have read and understood the explanation of the tattoo procedure. ____ I agree to follow the instructions and guidance provided by the tattoo artist. ____ I will provide accurate and honest information about my health, medical conditions, allergies, or medications that may affect the tattoo process or aftercare. ____ It is my responsibility to advise the Technician of any concerns I may have before the procedure. ____ I consent to the agreed-upon design and placement of my tattoo. ____ I understand that there may be risks involved in the tattooing process, such as pain or discomfort during the procedure. ____ I am aware of the potential risks of allergic reactions to tattoo ink or other materials used. ____ I understand the importance of following proper aftercare instructions to avoid infection and ensure the healing of my tattoo. ____ I acknowledge that tattoos may fade or blur over time due to factors beyond the artist's control, such as sun exposure, skin type, and lifestyle. ____ I understand that removing or modifying the tattoo in the future may be difficult * Please agree by entering your name below I, ___________________________________ hereby give permission for any photos, videos, or audio that are taken of me to be used in and/or for any lawful promotional materials, such as but not limited to newsletters, flyers, posters, brochures, advertisements, press kits, websites, social media pages, and other print and digital communications. This authorization shall continue indefinitely and extends to all languages, media, formats, and markets now known or later discovered. I renounce all claims I may have to royalties or other forms of payment resulting from or connected to the use of the image or sound recording. I understand and agree that these materials shall become the property of Nocturnal Ink and will not be returned. All claims that I, my heirs, representatives, executors, administrators, or any other person acting on my behalf or on behalf of my estate may hold harmless and release them from any claims that they may bring. By signing below, I hereby acknowledge that I have completely read and fully understand the above * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Thank you!
