Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Legal Statements & Acknowledgements *

I am at least 18 years old. I understand tattoos cannot be performed on minors in California (no exceptions).

I am not under the influence of drugs or alcohol.

I understand tattooing is permanent and may only be removed with a procedure that may leave scarring or be costly.

I understand tattoo inks, dyes, and pigments have not been approved by the U.S. Food and Drug Administration and the health consequences are unknown.

I have received written aftercare instructions that include: (1) how to care for the tattoo site; (2) activity restrictions & durations; (3) signs of infection; and (4) when to seek medical care.

I understand the risks involved, including infection, allergic reactions, scarring, keloids, and other complications.

Medical Questionnaire

Please check the box if any of the following are true and inform your artist.

Are you pregnant or possibly pregnant?

History of herpes at proposed site?

Do you have diabetes?

Do you have hemophilia or a bleeding disorder?

Do you have cardiac valve disease?

Do you have allergies to latex?

Do you have allergies to antibiotics?

List any current/recent medications (including prophylactic antibiotics for dental/surgical procedures)

Other Z pathogen risk factors

Media Release

I grant permission for photographs/video of my tattoo to be used for promotional purposes. I understand declining this does not affect my service.

I Agree

Tattoo Aftercare Instructions *

• Wash your hands before touching your tattoo. • Remove bandage after amount of time instructed by your artist. • Gently wash tattoo with mild, fragrance-free soap and lukewarm water; pat dry. • Apply a thin layer of the recommended ointment; do not over-apply. • Avoid soaking in water (baths, swimming, hot tubs) for at least 2 weeks. • Avoid direct sunlight and tanning beds until fully healed. • Do not scratch or pick at scabs or peeling skin. • Avoid contact with animals and gardening activities for at least 2 weeks. • Signs of infection include redness, swelling, pus, excessive pain, or fever—seek medical care if these occur. • For health concerns, contact the Orange County Body Art Program at 714-433-6000. For any further questions or clarification, please do not hesitate to reach out to our team.

Client confirms receipt of these aftercare instructions.