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Health Declaration & Consent Form

Please fill out the following form before arriving to your Tattoo Appointment.

All of your medical information is confidential under HIPAA regulations and will not be disclosed to anyone other than relevant shop staff and artists. If you have any questions on how certain medical conditions can affect tattoos, please speak with your artist prior to your session.

First name

Last name

Street Address

Street Address Line 2

City

Postal / Zip code

Region/State/Province

Country

Phone

Email

Are you prone to fainting?

Are you allergic to adhesives?

Are you allergic to latex?

Are you currently taking antibiotics?

Are you currently taking blood thinners?

Are you currently taking anti-rejection drugs?

Are you currently taking acne medication?

Do you have or have you ever had: (check all that apply)

Hepatitis

Herpes

Hemophelia

HIV/AIDs

Heart Disease

Psoriasis

Lymphedema

Eschemia

Syphilis

Diabetes

Melanoma

Keloid scarring

Gonorrhea

Epilepsy

None of the above

When was your last meal?

Please list any allergies:

Please add any additional information you believe is important for your tattoo artist to know about you:

I specifically acknowledge that I have been advised of the facts and matters set forth below, and I agree as follows:

I acknowledge that I am not pregnant.

I acknowledge that I am free from communicable diseases.

I acknowledge that I have been truthfully represented to the employees, agents, and representatives of Under the Sun Tattoo that I am 18 years or older.

I acknowledge that is not reasonally possible for the representatives and employees of Under the Sun Tattoo to determine whether I might have an allergic reaction to the dyes, pigments, or processes used in my tattoo, and I agree to accept the risk is a possibility.

I acknowledge that infection is always a possibility as a result of obtaining a tattoo, particularly in the event that I do not take proper care of my tattoo.

I acknowledge receipt of the written instructions advising me of the proper care of my tattoo and I recognize this absolute necessity for following those instructions.

I acknowledge that variation in color and design may exist between any tattoo selected by me and as ultimately applied to my body.

I acknowledge that a tattoo is a permanent change to my appearance and that no representations have been made to me as to the ability to later change of remove my tattoo.

I acknowledge that the obtaining of my tattoo is by my choice alone and I consent to the application of the tattoo and to any actions or conduct of the employees of Under the Sun Tattoo, reasonably necessary to perform the tattoo procedure.

I confirm that I consider myself healthy to undergo a tattoo procedure, I do not hold LA Arts DBA Under the Sun Tattoo or its affiliates responsible for any advers effects or reactions resulting from my tattoo due to failure on my part to disclose any pertinent medical conditions to my artist and/ or failure to follow proper aftercare protocol.

I agree to release and forever discharge and hold harmless, Under the Sun Tattoo and its agents, employees, representatives, officers, and share holders from any and all claims, damages or legal actions arising from or connected in any way with my tattoo or procedures and conduct used to apply my tattoo.

I consent to future tattoo work such as touch-ups and/or multiple sessions for this tattoo if deemed necessary between myself and the tattooer.

I agree to give Under the Sun Tattoo consent to publish any and all photos of my tattoo(s).

Select you Artist

Date of Your Tattoo Appointment:

Government Issue Photo ID

Upload Photo ID

Upload supported file (Max 15MB)

I declare that the info I’ve provided is accurate & complete

Your Signature

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Under the Sun Tattoo

​Health Declaration & Consent Form

Health Declaration & Consent Form