Name *

First Name

Last Name

Select if applicable to you

Diabetes

Pregnant/Breast feeding

Heart condition

Herpes

Anticoagulant

High blood pressure

Hemophilia

Asthma

Eczema

Epilepsy

Infection

Consent *

-I was able to ask all the questions I wanted and I got all the answers I needed. -I certify that I'm over 18 years of age -I certify that I am not under the influence of alcohol or drugs -I understand there's a possibility of an allergic reaction -I understand there's a possibility of infection -I agree to follow the instruction given for post-tattoo care and I understand that there is a possibility of dizziness/loss of consciousness during and after the tattoo. If the latter happens, I will notify VILAINS TATTOO INC. -I understand that there are no refunds and that touch-ups are guaranteed for a period determined by your tattoo artist.

I consent

Date

MM

DD

YYYY

Confirmation *

I confirm that the information provided in this form is true and that my consent is free and informed. I also confirm and accept that VILAINS TATTOO INC. , it's owner and employees cannot be held accountable in the event of complications following the tattoo.

Appointment *

Help us compile the number of walk in we get during the year!

I have a scheduled appointment

I came as a walk in!

Is it your first time at Vilains Tattoo? *

To help us compile statistics over the years, thanks!

Yes

No