Kilburn Original Tattoo

Let us do this part

Today's Date:

Wed Mar 25 2026 10:04

Practitioner:*

Please read and answer

How did you hear about us?

Have you eaten today?*

Diabetes*

Epilepsy*

History of heart disease*

Allergies to latex/adhesive bandages*

Currently on medication*

HIV or Hepatitis B/C*

Pregnant or breastfeeding*

Medical conditions that may cause haemorrhaging*

Photography/Videos*

I release all rights to any photographs taken of me and the tattoo and give consent in advance to their reproduction in print or electronic form.

Influence*

I am not under the influence of alcohol or drugs, and I am voluntarily submitting to be tattooed by the Artist without duress or coercion.

Spelling/translation*

Neither the Artist nor the Tattoo Studio is responsible for the meaning or spelling of the symbol or text that I have provided to them or chosen from the flash (design) sheets.

Risks*

That I have been fully informed of the inherent risks, associated with getting a tattoo. I fully understand that these risks, known and unknown, can lead to injury, including but not limited to infection, scarring, difficulties in detecting melanoma and allergic reactions to tattoo pigment, latex gloves, and/or soap. Having been informed of the potential risks, I still wish to proceed with the tattoo application and I freely accept and expressly assume any and all risks.

Agreement*

I have answered this form truthfully and to the best of my knowledge.
I understand that there is a possibility that my tattoo could become infected if I do not look after it as instructed.
I agree that any touch up work needed, due to my own negligence will be carried out at my own expense.
I also understand that a tattoo is a permanent change to my appearance
I can confirm I am over the age of 18 and have shown proof of age (photo attached at the bottom of the form).

GDPR

I have read and understood the Stabpad privacy policy for completing this form, found on the following link: hhtps://www.stapbad.com/privacy

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:*

Pronouns:

Chosen name:

Address:

Postcode:

Date of birth:*

You must be 18 or older

Age:

Phone #:*

Email:*

Social Handle:

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

Signature:*

Sign or type signature:

Photo Identification *

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