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Consent Form

RA Tattoos - Client Consent Form

Health declaration

Please fill out the following form.

First name*

Last name*

Email*

Address

Date of birth*

Day

Month

Year

Do you currently suffer from, or have you ever suffered from any of the following?

Heart Condition / Angina*

No

Yes

Blood pressure problems*

No

Yes

Epilepsy / Seizures*

No

Yes

Haemophilia / Blood clotting disorders*

No

Yes

Skin complaints e.g. psoriasis, eczema, dermatitis*

No

Yes

Diabetes*

No

Yes

Allergic Response e.g. anaesthetics, jewellery, latex*

No

Yes

Are you prone to fainting?*

No

Yes

Do you take blood thinning medication?*

No

Yes

Do you take any regular prescribed medication?*

No

Yes

Could you be pregnant?*

No

Yes

Any other condition that could impact the process or healing of your tattoo?*

No

Yes

Please provide details if you have answered 'yes' to any of the above.

I declare that the info I’ve provided is accurate and complete.

I give my consent to the use of photographs/video of the tattoo for social media and advertising

Signature*

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Email:

ratattoo33@gmail.com

Wimborne Rd, Bournemouth, UK

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