Name *

First Name

Last Name

Phone *

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Tattoo Artist *

Jill I (@jdawn.tattoo).

Sarah I (@sarahgal_tattoo).

Colleen I (@gurl_soul).

Moon I (@moonberry.tattoos).

Eilidh I (@chemloadtattoos).

Laura-Chanel I (@laurachanelart).

Guest Artist.

Do you have a history of allergies or adverse reactions to nitrile, pigments, dyes, disinfectants, metals, adhesives, or other sensitives related to body art procedures? *

No.

Yes (please discuss with your artist prior to your tattoo).

Do you have a history of epilepsy, seizures, fainting or narcolepsy? *

No.

Yes (please discuss with your artist prior to your tattoo).

Have you had any complications with a tattoo before? *

No.

Yes (please discuss with your artist prior to your tattoo).

Are you on any medication or have any condition that may affect blood circulation and/or ability to fight infection? *

No.

Yes (please discuss with your artist prior to your tattoo).

Are you currently pregnant and/or breastfeeding? *

No.

Yes (you cannot be tattooed at this time).

Have you eaten in the last 4 hours (piror to appointment, please be sure to eat beforehand)? *

Yes.

No.

Do you consent to your artist and/or Black Eleven Tattoo to release the rights of the photos and/or videos taken of your tattoo for the use of social media, promotion, and portfolios? *

Yes.

No.

I hereby state that I am over the age of 18, therefore able to consent to receiving this tattoo *

Yes.

I am under my own free will and under no influence of any other person to be tattooed, nor am I under the influence of any drugs and/or alcohol. *

Yes.

I consent to receiving a tattoo, that it is a permanent change to my physical appearance. *

Yes.

I understand that tattoo removal may not be possible, or if possible may result in scaring. *

Yes.

I accept and am responsible for all risks and care of the tattoo. Not limited to infections, blowout, & reactions both during and after the tattoo. *

Yes.

I accept all responsibility for the agreed upon design/text from initial design, alterations, to final tattoo. I have carefully looked over the design, all grammar, punctuation and spelling of said tattoo and hereby consent to this tattoo. *

Yes.

I will follow the advice and aftercare provided to me by the artist and/or Black Eleven Tattoo. I understand that if I do not follow, I am responsible for any negative results. *

Yes.

I understand and accept that certain medications and/or conditions may interfere with the tattoo and the healing process and that this could increase complications and/or healing time. *

Yes.

I attest that I am not experiencing any symptom of illness such as cough, shortness of breath or diffculty breathing, fever, chills, repeated shaking with chills, muscles pain, headache, sore throat, or new los of taste or smell. *

Yes.