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UNITED TATTOO CONSENT FORM
5160 FONTAINE BLVD
FOUNTAIN, COLORADO 80817
www.united-tattoo.com
(719) 698-9004
TATTOO ARTIST:
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TATTOO APPOINTMENT DATE:
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FIRST NAME
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EMAIL ADDRESS
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PHONE
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TATTOO DESCRIPTION:
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CHECK ANY CONDITIONS LISTED BELOW THAT APPLY TO YOU:
Asthma
Bleeding Disorder
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Faint/ Dizzy
Heart Condition
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Immunocompromised Status
Infection(s)
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Tuberculosis
CHECK ANY ALLERGIES OR ADVERSE REACTIONS THAT APPLY TO YOU:
Alcohol/ Witch Hazel
Disinfectants
Dyes/ Pigments
Latex
Lidocaine
Metals
Penicillin
Petroleum Products
Shellfish
Soaps
Vitamin A or D
ANY ALLERGIES, MEDICATIONS, OR INFECTIONS THAT COULD AFFECT THE HEALING PROCESS?
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