Consent form Name * First Name Last Name Email * Phone number * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of birth * Proof of Age/Photographic Identification may be required MM DD YYYY Todays date * MM DD YYYY Artist * Mowgli Emma Mia Matt Guest Artist Description and placement of tattoo * Medical information Do you suffer/have you suffered any of the following Covid-19 * Have you been unwell or had symptoms of Covid-19 in the last 14 days? (This includes people that you live with or have been in contact with) YES NO Heart Disease/Conditon * YES NO Eczema * YES NO Impetigo * YES NO Haemorrhaging/Haemophilia YES NO Epilepsy/Siezure * YES NO Diabetes * YES NO HIV * YES NO Hepititis A,B,C * YES NO Acne * YES NO Psoriasis * YES NO Cellulitis * YES NO Keloid scarring * YES NO Prone to fainting/dizziness * If at any time you feel faint or funny, please let your artist know YES NO Do you take any medication that may thin your blood? * This includes aspirin YES NO Allergy to Adhesive Plasters/Micropore/Jewellery/Metals/Latex etc * YES NO Please list any allergies you have below If you have ticked YES to any of the above, please discuss with your artist, as you may need to consult your GP before proceeding with the tattoo Have you eaten in the past two hours? * Eating something filling is important as it reduces the likelihood of becoming lightheaded during tattooing. The body will be more prepared for the stamina and energy needed for your session. YES NO Film/Photograph * During your session we may take pictures or do some filming. Do we have permission to do so? We may use the footage on our social media pages. YES NO If you'd like to be tagged please leave your Instagram handle below Payment On completion of your session you are required to pay your artist in full before you leave the studio I AGREE Newsletter Our monthly newsletter includes information about our artists' booking schedules, guest artists, special events such as flash days and client days, new content, etc. If you'd like to receive our newsletter via email, please click the box below. If you would not like to receive it, leave the box blank. I would like to receive the newsletter Declaration I the client named above fully understand that I must be 18 years of age or over to be tattooed and present proof of Identification if requested. I give the chosen Artist of Through My Third Eye Tattoo, 342 Hornsey Road, Permission to tattoo me and understand the irreversible nature of the procedure. I declare that I am not under the influence of drugs or alcohol. I understand the importance of following the daily aftercare advice given to me by the Artist, and how not following this advice could lead to that tattoo not healing correctly. I.E., looking patchy or becoming infected, for which the Artist and Through My Third Eye will not be liable. I also confirm that I have been given the written tattoo aftercare instructions to take away with me after the procedure. Signed * Thank you!