Consent Form

The consent form is below. Please fill out to the best of your ability.

First name

Last name

Email

Yes, subscribe me to your newsletter.

Multi-line address

Country/Region

Address

City

Zip / Postal code

Birthday

Day

Month

Year

ID upload with date of birth & photo on

Phone

GP Surgery and address

GP Surgery Phone

Date of your appointment

Short description of tattoo, placement and placement side. E.g. birth flower on right inner bicep.

Do you have any medical conditions that could affect your appointment or post tattoo care?

A non exhaustive list: allergies, diabetes, blood disorders, autoimmune disease, cancer, epilepsy, skin disease on the area to be tattooed, low/high blood pressure. Also if you are taking any medications that could affect the healing of your tattoo e.g. blood thinners. Please note I cannot give medical advice, if you have been cleared by your doctor then it's okay by me and I will not turn you away.

Would you like a quiet appointment?

Yes

No

Preferred pronouns:

Do you consent for photos and/or videos of your tattoo to be taken? They may be shared in my online portfolio and can be completely anonymous (no identifying features/faces etc).

Yes

No

If you would like me to tag you on Instagram please share your handle below.

Please read carefully the terms and conditions below. By ticking each box you are agreeing to abide by each statement.

I confirm the information I have put in the form is accurate and correct to the best of my knowledge.

I can confirm I am 18 years old or over which is the legally minimum age to be tattooed. If I look under 25 I will bring ID (passport, drivers license, student ID) to the appointment.

I can confirm I will not be under the influence of drugs or alcohol at the time or date of my appointment.

I can confirm I am not pregnant, breastfeeding or trying to conceive at the time of the appointment.

I understand that tattooing has potential risks, these include allergic reaction, localised swelling, blood poisoning (scepticaemia) and scarring.

I agree to follow all pre-care and post care advice for my tattoo. I understand that by not doing so may result in poor healing, infection or aging poorly.

I understand that a handpoke tattoo is permanent.

I understand that the healed tattoo will look different from the fresh tattoo.

I understand that the tattoo design will not look exactly like the final design.

I fully consent to being tattooed by Gem Smith at Heartwood Tattoo Studio.

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HEARTWOOD

Consent Form