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Dinamik Tattoo
AUTHORIZATION FORM
Authorization Form
Please select your artist.
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Select your artist
Aric Taylor
Abrum Stoft
Scott Grosjean
Albert Padron
Adrian Quintero
Chris Burnett
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Full Name
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DOB
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Sex
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Email
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Phone
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Address
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Emergency Contact
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Emergency Contact Phone
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Please select any conditions that may apply to you.
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Diabetes
Hemophilia
T.B.
Asthma
Heart-conditions
Epilepsy
Blood-thinners
Eczema/Psoriasis
Allergic reaction to antibiotics
Pregnancy/Nursing
Fainting or Dizziness
Herpes
Scarring/Keloiding
Allergic reaction to latex
Skin conditions
None
How long has it been since you last ate?
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Do you have any allergies?
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Yes
No
If yes, please explain
Do you use any medications that might affect the healing of the body art you will receive?
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Yes
No
Do you have any other medical or skin conditions that may affect the outcome of your procedure?
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Yes
No
Have you ever been prescribed antibiotics prior to dental or surgical procedures?
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Yes
No
Is there any other information you feel you should provide to the body art practitioner?
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Yes
No
If Yes
All Questions about the body art procedure have been answered to my satisfaction, and I have been given written aftercare instructions for the procedure I am about to receive.
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Yes
No
The body piercing described or shown on the client record form is correctly placed to my specification.
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Yes
No
Does Not Apply
The body tattoo described or shown on the client record form is correctly placed to my specification.
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Yes
No
Does Not Apply
I understand that tattooing is permanent and that if I choose to have it removed, it may be expensive, and leave scars.
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Yes
No
Does Not Apply
I am the person on the legal ID presented as proof that I am at least 18 years of age/
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Yes
No
I am not under the influence of alcohol or drugs, and I am voluntarily submitting to be tattooed without duress or coercion.
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Yes
No
I understand there is a possibility of an allergic reaction.
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Yes
No
I understand there is a possibility of getting an infection.
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Yes
No
I agree to follow all instructions concerning the care of my tattoo or piercing, and that any touch-ups needed due to my own negligence will be done at my own expense.
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Yes
No
I understand that there is a chance I might feel lightheaded - dizzy, during or after the procedure.
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Yes
No
I agree to immediately notify the artist in the event I feel lightheaded - dizzy, before, during, or after the procedure.
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Yes
No
I understand that tattoo inks, dyes, and pigments have not been approved by the Federal Food and Drug Administration and that the health consequences of using this products are unknown.
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Yes
No
By submitting this form I acknowledge that I have been fully informed of the risks of tattooing, including but not limited to: infection, scarring, difficulties in detecting melanoma, allergic reactions to tattoo pigment, latex gloves, and antibiotics. Having been informed of the potential risks associated with getting a tattoo, I still wish to proceed with tattoo application, and I assume any and all risks that may arise from tattooing.
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I consent
I do not consent
Signed
Clear
Dated
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Appointment Request
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14875 BEAR VALLEY RD. HESPERIA, CA, 92345
