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Tattoo Waiver, Release, & Consent Form

Maria Elisabeth

Client Information

Birthday
Year
Month
Day

Pre-Procedure Questionnaire

Are you at least 19 years old?
Yes
No
Are you under the influence of drugs or alcohol or have been in the less 24 hours?
Yes
No
Are you prone to fainting?
Yes
No
Are you pregnant or nursing?
Yes
No
Are you currently menstrating?
Yes
No
Do you have a communicable disease? (Example: HIV, Hepatitis, ect.)
Yes
No
Have you had any surgeries or been hospitalized in the last few months?
Yes
No
Do you have any skin conditions? (e.g. Rashes, eczema, infection, psoriasis, moles, etc.
Yes
No

If yes, please identify the condition.

If yes, please identify the condition.

Acknowledgment and Waiver

Please read the following statements carefully and check to acknowledge you agree before continuing.

Signed Date
Year
Month
Day
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Thank you!

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