Welcome to Moth and Flame Tattoo…This will be the most painful part of your experience..If you have any questions whilst filling out this form, please ask your artist, thank you! Name * First Name Last Name Date of Birth * MM DD YYYY Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Next of kin * Contact incase of emergency Artist * Jason James James Keith Alice Flo Benny Smalls Yazmina Ferrer Guest Artist Guest artist name (if applicable) Description of Tattoo Placement of Tattoo Tick the boxes below if any apply to you: Medical advice should be sought in any of doubt as to whether procedure is suitable. If any question answered 'Yes' procedure to be reviewed and medical advice to be obtained. Suffers from any heart conditions (e.g. prosthetic heart value, heart valve disease, angina, blood pressure problems)? Suffers from epilepsy? Suffers from haemophilia / other clotting disorders? Suffers from any known blood borne virus e.g. Hep B, Hep C, Hep D, HIV)? Suffers from diabetes or lupus ? Suffers from any problems with skin healing in the past, (e.g. psoriasis, eczema)? Suffers from any ‘lumpy’ raised scars (keloid scars)? Suffers from any known allergic responses (eg plastic, creams, metals, iodine, shellfish, latex, food-stuff, other)? Takes any prescribed medication regularly (anticoagulants, Warfarin, high dose asprin, immuno-suppressants, or steroids)? Is the client pregnant? Prone to fainting attacks? Tattoo only : Any known / previous reaction to dye pigments? Consumed alcohol or drugs in the last 24 hours? Any other relevant information? If answered 'Yes' to any of the questions above please give details and let your artist know before starting... Consent to Tattoo Procedure I acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions which I might have about the obtaining of a tattoo and that all of my questions have been answered to my full satisfaction. I specifically acknowledge I have been advised of the facts and matters set forth and I agree as follows: If I have any condition, including but not to a blood condition, that might affect the healing of this tattoo, I will advise my tattooer. I am not pregnant or nursing. I am not under the influence of alcohol or drugs. I do not have a medical or skin conditions such as but not limited to acne, scarring (Keloid), eczema, psoriasis, freckles, moles or sunburn in the area to be tattooed that may interfere with said tattoo. If I have any type of infections or rash anywhere on my body, I will advise my tattooer. I acknowledge it is not reasonably possible for the representatives and employees of this tattoo shop to determine whether I might have an allergic reaction to the pigments or processes used in my tattoo, and I acknowledge that such a reaction is possible. I acknowledge that infection is always possible as a result of obtaining of a tattoo, particularly in the event that I do not take proper care of my tattoo. I have received aftercare instructions and I agree to to follow them while my tattoo is healing. I agree that any touch-up work needed, due to my own negligence will be done at my own expense. I realize that variations in colour and design may exist between any tattoo as selected by me and as ultimately applied to my body. I understand that if my skin colour is dark, the colours will not appear as bright as they do on light skin. I understand that tattooing certain areas of the body may be more likely to result in natural reactions such as, but not limited : bleeding ink, keloid scarring or warping which may affect the final appearance of the tattoo. I acknowledge that only I who signs my consent to this procedure is allowed to enter the procedure area. I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to the tattoo. I acknowledge that a tattoo is a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove my tattoo. To my knowledge, I do not have a physical, mental or medical impairment or disability, which may affect my well being as a direct result of my decision to have a tattoo. I understand that the studio operates as an inclusive, hate-free space and enforces a zero-tolerance policy for discriminatative or abusive speech or behaviour of any kind. I understand that my session will be terminated immediately and I will be asked to leave the tattoo shop if this policy is breached. The studio is monitored by CCTV. I understand images and photos are frequently taken at the studio for social media and/or promotional use. The studio has unrestricted rights to use any image taken within its premises. Any special request is subject to approval by the artist and the studio and if applicable, additional fees. I acknowledge I am over the age of eighteen and that I have truthfully represented to my tattooer that the obtaining of a tattoo is my choice alone. I consent to the application of the tattoo and to any action or conduct of the representative and employees of the tattoo shop reasonably necessary to perform the tattoo procedure. Newsletter * I wish to receive news from Moth and Flame about flash days, events and merchandise. I DO NOT wish to receive news from Moth and Flame about flash days, events and merchandise. SIGNED * Date * MM DD YYYY Thank you! We hope you enjoy your time here at Moth and Flame, if you could leave us a google review after you finish, we’d much appreciate it…
