CONSENT FORM NAME OF PRACTITIONER: First Name Last Name NAME OF CLIENT: * First Name Last Name EMAIL OF CLIENT: * ADDRESS OF CLIENT: * TEL NO. OF CLIENT: * DATE OF BIRTH OF CLIENT: * MM DD YYYY TATTOO DESIGN AGREED ON: YES NO DESCRIPTION & PLACEMENT OF TATTOO: * NOTE: Medical advice should be sought in any case of doubt as to whether procedure is suitable. SUFFERS FROM ANY HEART CONDITIONS (e.g. prosthetic heart valve/ heart valve disease/ angina/ blood pressure problems)? * YES NO ACTION: If question answered ‘YES’ procedure to be reviewed and medical advice to be obtained. SUFFERS FROM EPILEPSY? If Yes, how controlled? * YES NO ACTION: If question answered ‘YES’ procedure to be reviewed and medical advice to be obtained. SUFFERS FROM HAEMOPHILIA/OTHER CLOTTING DISORDERS? * YES NO ACTION: If question answered ‘YES’ procedure to be reviewed and medical advice to be obtained. SUFFERS FROM ANY KNOWN BLOOD BORNE VIRUS (e.g. Hep B, Hep C, Hep D, HIV)? * YES NO ACTION: If question answered ‘YES’ procedure to be reviewed and medical advice to be obtained. SUFFERS FROM DIABETES OR LUPAS? * YES NO ACTION: If question answered ‘YES’ procedure to be reviewed and medical advice to be obtained. SUFFERS FROM ANY PROBLEMS WITH SKIN HEALING IN THE PAST, e.g. psoriasis, eczema? * YES NO ACTION: If question answered ‘YES’ procedure to be reviewed and medical advice to be obtained. SUFFERS FROM ANY 'LUMPY' RAISED SCARS (keloid scars)? * YES NO ACTION: If question answered ‘YES’ procedure to be reviewed and medical advice to be obtained. SUFFERS FROM ANY KNOWN ALLERGIC RESPONSES - e.g. plasters/creams/ metals/iodine/shellfish/latex/food-stuffs/other? Indicate which: * YES NO ACTION: If question answered ‘YES’ procedure to be reviewed and medical advice to be obtained. TAKES ANY PRESCRIBED MEDICATION REGULARLY (especially any anticoagulants such as Warfarin or high dose asprin; any immuno-suppressants such as steroids)? If Yes, list which: * YES NO ACTION: If question answered ‘YES’ procedure to be reviewed and medical advice to be obtained. IS THE CLIENT PREGNANT? * YES NO ACTION: If question answered ‘YES’ procedure to be reviewed and medical advice to be obtained. PRONE TO 'FAINTING ATTACKS'? If yes, state reason: * YES NO ACTION: If question answered ‘YES’ procedure to be reviewed and medical advice to be obtained. ANY KNOWN/PREVIOUS REACTION TO DYE PIGMENTS? * YES NO ACTION: If question answered ‘YES’ procedure to be reviewed and medical advice to be obtained. ANY OTHER RELEVANT INFORMATION * YES NO TIME OF ARRIVAL: NAME OF CLIENT: * DATE: * MM DD YYYY Thank you!
