client intake and medical historyPlease fill out the information below and contact your artist for any further questions or concerns. Name * First Name Last Name Date * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of birth * MM DD YYYY Email * Emergency Contact Name First Name Last Name Emergency Contact Phone Number * Country (###) ### #### Have you eaten within the past 4 hours * Yes No Are you under the influence of drugs or alcohol? * Yes No Have you ingested anticoagulants (such as heparin or warfarin), antiplatelet drugs, or nonsteroidal anti- inflammatory drugs (NSAIDS) (such as aspirin, ibuprofen, etc.) in the last 24 hours? * Yes No Have you ingested any medication that can inhibit the ability to heal a skin wound? * Yes No Do you have any allergies or adverse reactions to dyes, pigments, latex, iodine, or other such products? * Yes No Do you have hemophilia, epilepsy, a history of seizure, fainting, narcolepsy, or other conditions that could interfere with the body art procedure? * Yes No Do you have a history of skin diseases that might inhibit the healing of the body art procedure? * Yes No Do you have any communicable diseases (i.e., hepatitis A, hepatitis B, HIV, or any other disease that could be transmitted to another person during the procedure)? * Yes No Do you have diabetes, high blood pressure, heart condition, heart disease, or any other conditions that could interfere with the body art procedure? * Yes No Are you currently under the care of a physician/dermatologist? * Yes No Current medications: Are you pregnant? * Yes No Are you Breastfeeding? * Yes No Have you had Hepatitis and Jaundice in the last 12 months? * Yes No Allergies or Sensitives? * Check all that apply. Food Latex Epinephrine Lidocane Hydrocortisone Hydroquinone or Nickl/Metals Do you have any of the following Medical Conditions? Check all that apply. Cancer Diabetes Hemophilia Keratosis Vitiligo HIV/AIDS Hepatitis Keloids High Blood Pressure Herpes Arthritis Seizure Heart Condition Blood Clotting Skin Disease Hormone Imbalance Thyroid Imbalance Jaundice If you book an appointment with any of above restrictions and are unable to be treated, your appointment may be subject to cancelation and you will forfeit your deposit. All payments are non-refundable. If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document. I hereby declare that I am of legal age (and have provided valid proof of age and identification) and am competent to sign this Agreement. I HAVE READ THE AGREEMENT, I UNDERSTAND IT, AND I AGREE TO BE BOUND BY IT.**PLEASE ASK YOUR ARTIST ABOUT THE PRICE OF YOUR TATTOO BEFORE BEGINNING THE PROCEDURE - it is your responsibility to confirm the price of the tattoo, and we assume no responsibility for any misunderstanding in this regard. By signing your full name below, you acknowledge you have thoroughly read through and understand all policies in full clarity, and agree to abide by the penalties in place. * First Name Last Name Thank you!