Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date of Birth (must be 18+) *

MM

DD

YYYY

Are you under the influence of alcohol or drugs? *

YES

NO

Do you have any allergies (ink, latex, soap, etc.)? *

YES

NO

Do you have any medical conditions (skin disorders, diabetes, epilepsy, heart conditions, etc.)? *

YES

NO

Are you pregnant or nursing? *

YES

NO

I understand that the Tattoo Studio has a NO REFUND policy on Tattoos. *

I will not ask for a refund for any reason whatsoever.

I UNDERSTAND

Artist Name *

First Name

Last Name