Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone

(###)

###

####

Phone

(###)

###

####

Please check any conditions listed that apply to you: *

Diabetes

Epilepsy

Hepatitis

HIV

Hemophilia

Scarring/Keloiding

Pregnant

Nursing

Heart Condition

Herpes

Blood Thinners

NONE OF THE ABOVE

I have been informed about the tattoo procedure, including the potential risks and aftercare instructions. I consent to the tattoo procedure. *

Agree

I acknowledge that I am responsible for following the aftercare instructions provided by the tattoo artist. I release the tattoo artist TAIOM from any liability for complications or reactions that may arise from the tattoo procedure. *

Agree

I am NOT under the influence of DRUGS or ALCOHOL *

Correct

I hereby certify that to the best of my knowledge this information is correct *

Correct