Tattoo Consent Form - HANA WOLHF

First name *

Last name *

Date of Birth *

Phone *

Email *

Address *

Date of appointment *

Medical History

Do you have a communicable disease, such as but not limited to HIV, Hepatitis A, B, & C? *

Yes

Do you have any skin conditions (e.g eczema, impetigo, psoriasis, ketosis pilaris etc)? - YES or NO *

{If yes please identify the condition above}

Have you suffered from the following: Diabetes, heart disease / condition, epilepsy / seizures, blood-related diseases? - YES or NO *

{If yes please identify the condition above}

Please detail any other blood, skin, or health condition that your tattoo artist should know about *