Medical History Questionnaire

This form must be completed online or in person before your tattoo.

Disclosing your medical information is voluntary. Any information you provide is confidential and will only be used to ensure your safety during the tattoo procedure.

Please answer the following questions to the best of your ability. Whether or not you choose to answer, you must sign this form indicating you understand the risks of non-disclosure.

Are you currently taking any medications?

I am taking these medications

Do you have any allergies?

I am allergic to

Have you had any surgeries in the past year?

Are you pregnant or nursing?

Have you ever experienced any of the following (check all that apply)

Skin disorders (eczema, psoriasis, etc.)

Heart conditions

Diabetes

Hepatitis or other liver conditions

HIV/AIDS

Blood disorders (e.g., hemophilia)

Autoimmune disorders

Keloid scarring

Any other health conditions

(please specify )

Have you/will you consume alcohol or recreational drugs in the 24 hours prior to receiving your tattoo?

Do you have any other medical conditions that may affect the healing of a tattoo?

Have you ever had a negative reaction to a tattoo or body art procedure?

Do you have any other questions regarding the tattoo procedure?

I have eaten / will eat within a few hours of receiving my tattoo

I acknowledge that the above information is accurate to the best of my knowledge. I understand that failure to disclose any relevant medical information may affect the safety and outcome of the tattoo procedure.

First name

Last name

Email

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.