Date of Birth / / Are you over the age of 18? YesNo Are you pregnant or breast feeding? YesNo Do you have a history of Hemophilia or excessive bleeding? YesNo History of skin disease, skin lesions, or skin sensitivities to soaps of disinfectants? YesNo History of allergies or adverse reactions to latext, pigments, dyes, disinfectants, metals or other sensitivities related to tattoo procedures? YesNo History of epilepsy, seizures, fainting, narcolepsy or eye disease? YesNo Have you ever had a treatment with anticoagulants or medications that thin the blood and/or interfere with blood clotting? YesNo Are you currently or have you used RETIN A, RENOVE, LASH GROWTH products, Hydroxyl (Glycolic) Acid or ACCUTANE? YesNo Do you have Diabetes? YesNo Do you have a history of Jaundice? YesNo Do you have allergies to anesthetics? YesNo Do you have any serious medical conditions? YesNo Have you ever been tested positive of HIV or Hepatitis? YesNo History of Cancer at the site of service? YesNo Any other information that would aid the artist in your procedure or healing? YesNo Any client reporting one or more of the above conditions is advised to consult their physician before undergoing a body art procedure. Subscribe to email and SMS updates * All fields are required