Tattoo Consent Form

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Let us do this part

Today's Date:

Sun Dec 14 2025 10:01

Practitioner:*

Artist signature:*

Royal Gothic Tattoo Studio
285 W Broadway
New York
10013
USA

Please read and answer

Over 18?*

Are you over the age of 18?

Eaten*

Have you eaten prior to attending your appointment?

Medical Conditions*

I confirm that if necessary I have sought medical advice to determine whether the procedure of tattooing is suitable and save to proceed with.

Do you suffer from and heart condition?

(e.g. Prosthetic heart valve/heart value disease/angina/blood pressure problems)?

If yes please give further details

Details:

Do you suffer from epilepsy?

If yes, how controlled?

Details:

Do you suffer from haemophilia/other clothing disorders?

Details:

Do you have any blood bourne Virus?
(e.g. Hep B, Hep C, Hep D, HIV, AIDS)?

If Yes please give further details.

Details:

Do you suffer from Diabetes or lupus?

If Yes please give further details on how controlled and any medication

Details:

Have you suffered and problems with skin healing in the past?

(e.g. psoriasis, eczema)?

If Yes please give further details.

Details:

Have you ever suffered from any 'lumpy' raised scars (keloid scars)?

If Yes please give further details.

Details:

Have you ever had any known allergic responses?

(e.g. Band aids/creams/metals/iodine/shellfish/latex/ foods/other?

If Yes please give details

Details:

Do you take any prescribed medication regularly?
(especially and anticoagulants such as warfarin or high does aspirin or any immune-suppressants such as steroids?)

If Yes please list these medications below.

Details:

Are you prone to 'fainting attacks'?

If yes, state reason.

Details:

Have you ever had any known/previous reaction to dye pigments?

If Yes please give details of when and dye pigments used.

Details:

Any other relevant information?

If Yes please give details

Details:

I understand that any medical information obtained will be subject to the federal Health Insurance Portability and Accountability Act of 1996
(HIPAA).

Pregnancy/Nursing*

Are you pregnant or nursing a child.

Under the influence *

I am not under the influence of alcohol or drugs and that I am voluntarily submitting myself to receive body art without duress or coercion.

Permanence*

I understand that a tattoo is considered permanent and may only be removed with a surgical procedure.

I understand and accept that this tattoo is a permanent change to my skin. I also accept that the tattoo will naturally change and fade over time and that this can e exacerbated by my not taking the appropriate steps to care for my tattoo, such as avoiding getting sun tanned or burned.

The body art described or shown on this form is correctly placed to my specifications. If applicable, I have also confirmed all spelling and grammar necessary in the procedure.

I understand the restrictions associated with this body art procedure as explained by the technician.

I understand that any effective removal of a tattoo or body piercing may leave scarring.

Spelling*

Neither the Artist nor the Tattoo Studio is responsible for the spelling of any text that I have provided to them, and I confirm that I am entirely responsible for checking that any spellings included in the design are correct before the tattoo begins.

Allergies*

Do you have any allergies that might effect getting tattooed?

Please give details if answering yes.

Details:

I agree that the artist and/or studio does not have any way of identifying if I am allergic to the elements or ingredients that will be used in my tattoo.

Acknowledgement and Waiver *

I confirm that I understand there are inherent risks associated with getting a tattoo and I still wish to proceed with the tattoo application and freely accept and expressly assume any and all associated risks.

Waive Liability *

I agree to waive and release to the fullest extent permitted by law each of the Artist and the Studio from all liability whatsoever for any and all claims or causes of action that I may have for personal injury or otherwise. This includes any direct and/or consequential damages which result or arise from my tattoo.

Studio waive Liability *

I agree to waive and release to the fullest extent permitted by law each of the Artist and the Studio from all liability whatsoever for any and all claims or causes of action that I may have for personal injury or otherwise whilst being within in the studio environment, including any direct and/or consequential damages.

I indemnify and hold harmless the Artist and tattoo studio against any claims, expenses, damages and Liabilities.

Associated Risks*

I understand there is a possibility of getting an infection as a result of receiving body art.

I am aware of the signs and symptoms of infection, including but not limited to, redness, swelling, tenderness of the procedure site, red streaks going from the procedure site towards the heart, elevated body temperature, or purulent draining from the procedure site.

I will seek professional medical attention if signs and symptoms of infection occur.

I understand that there is a chance that I might feel lightheaded or dizzy during or after being tattooed. I agree to immediately notify the artist in the event I feel lightheaded, dizzy, and/or faint before, during or after the procedure.

Variations*

Variations in color design may exist between the tattoo art I have selected and the actual tattoo when it is applied to my body. I also understand that over time colors and the clarity of the tattoo will fade due to unprotected exposure to the sun and the naturally occurring dispersion of pigment under the skin.

I agree to follow all instructions concerning the care of my body art procedure and that any touch-ups needed due to my own negligence will be done at my own expense

Questions*

All questions about the body art procedure have been answered to my satisfaction, and I have been given written aftercare instructions for the procedure I am about to receive.

Waiver and release*

Up on signing this release form I agree that I have been fully informed of the risks of body art including but not limited to infection, scarring, and allergic reactions to items associated with body art procedures. Technician will not perform the body art procedure if you fail to complete or sign this form. Further, technician may decline to perform a body art procedure if the client has any identified health conditions.

Having been informed of the potential risks associated with this body art procedure, I still wish to proceed with the body art application and I assume any/all risks that may arise from having this piece of body art.

Healing and Aftercare*

I confirm that I will accept the aftercare instructions given to me by the studio and follow these instructions while it's healing. I acknowledge that it is possible that the tattoo can become infected, particularly if I do not follow the instructions given to me. If any touch-up work to the tattoo is needed due to my own negligence, I agree that the work will be done at my own expense.

Photos*

I consent for any photographs taken of the tattoo to be used for social media or promotional purposes by the artist and studio.

Payment *

I confirm that I have paid in full for the service of tattooing dated on this release form.

Refund*

I acknowledge that the Artist and/or studio does not offer a refund.

I can confirm that the information that I have provided in this document is accurate and true.

Placement and Design*

Please state the intended placement area of your of your tattoo and a brief description of the design.

All of the above information will be kept in strict confidentiality

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.

Client Information

I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement.

Legal Name:*

Pronoun:

Chosen name:

Address:*

Postcode:*

Date of birth:*

You must be 18 or older

Gender:

Nationality:

Phone #:*

Email:*

Social Handle:

If you don't mind us tagging you in photos online

Signature:*

Sign above or type signature:

Emergency Contact

If something happens, your emergency contact might need to explain your medical history, allergies, or medications.

Name:

Phone #:*

Physician Information

Enter your physician or medical practitioner's contact details.

Name:

Contact:

Address:

Photo ID*

Please take photo(s) of your government issued photo IDs and related paperwork.