Tattoo Shop Consent + Medical Disclosure
A tattoo informed-consent and medical-disclosure form — client identity and age verification, design and placement, allergies and conditions affecting healing, medications, aftercare acknowledgment, photo-release consent, and signature.
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Iron Bird Tattoo
TATTOO INFORMED CONSENT + MEDICAL DISCLOSURE
CLIENT
Name: Riley Park
DOB: August 14, 1995 Age today: 30 ID: IL Driver License — last 4: 7720
Phone: +1 217 555 0151 Email: riley.park@example.com
Artist: Avery Tran
(This shop requires the client to be 18+ in jurisdictions that do not
allow tattooing of minors even with parental consent. Confirm local
age rule before scheduling.)
DESIGN & PLACEMENT
Description: Black-and-grey botanical sleeve — forearm 1/3 sleeve, peony + ferns, ~4 hours estimated. Final stencil reviewed and approved before needle contact.
Placement: Right forearm — outer side, wrist to inner elbow
Size / color: ~6×8 in · black-and-grey wash, no red
Final stencil reviewed and approved by client before needle contact: YES.
MEDICAL DISCLOSURE
Allergies: No known ink allergies. No latex allergy. No reaction to lidocaine topicals. Mild pollen allergy (not relevant to procedure).
Conditions: No diabetes. No hemophilia or bleeding disorder. No heart/valve condition requiring antibiotic prophylaxis. No autoimmune condition. Not pregnant. Not breastfeeding. No active skin condition at the tattoo site.
Medications: None. (Not on aspirin/blood thinners; not on isotretinoin/Accutane currently or within the past 6 months.)
Alcohol/drugs in past 24h: None.
Recent tattoo/piercing at site (30 days): None at this placement.
I confirm the above information is true and complete to the best of my
knowledge. I understand that conditions affecting healing or bleeding
(diabetes, hemophilia, autoimmune disease), blood thinners, isotretinoin
(Accutane within the past 6 months), pregnancy, breastfeeding, or active
skin conditions at the tattoo site may require postponement, a physician
clearance, or shop refusal to perform the procedure.
RISKS & INFORMED CONSENT
I understand that a tattoo is a permanent body modification carrying
inherent risks: pain during and after the procedure; bleeding and
swelling; localized infection (bacterial, rarely fungal/viral); allergic
reaction to ink components; scarring and keloid formation in
predisposed individuals; color migration and fading over time;
imperfect color match against unforeseen skin/healing variations; and
dissatisfaction with placement or design after healing.
I confirm the artist used single-use sterile needles from sealed
packaging in my presence; that surfaces and equipment have been
cleaned/disinfected per the shop's bloodborne-pathogens protocol; and
that I have been offered the opportunity to ask questions and receive
written aftercare instructions.
PHOTO RELEASE
Yes — face not shown
AFTERCARE
Aftercare instructions reviewed: Yes
I will follow the written aftercare instructions and contact the shop
or seek medical care if I observe signs of infection (fever, spreading
redness, pus, severe swelling beyond 72 hours).
SIGNATURES
Client: ____________________________ Date: ____________
Riley Park
Artist: ____________________________ Date: ____________
Avery Tran
(Retain this consent and disclosure form per state/local health-department
record-retention rules — commonly 2–7 years. Bloodborne-pathogens cleaning
logs, single-use needle records, and ink lot/batch numbers are kept
separately per OSHA and local rules.)
About this template
A **tattoo informed-consent and medical-disclosure form** is the shop's record that the client understood the procedure, disclosed conditions that affect bleeding and healing, and agreed to the **permanent body modification** about to happen. Several pieces must be in it. **Age verification** — most US states require the client to be **18 or older even with parental consent** (a handful permit 16/17 with notarized parental consent; confirm locally), so capture the **government-ID last-4** on the form. **Design, placement, and final stencil approval** — every artist who skipped the "final stencil reviewed in the mirror before needle contact" step lives to regret it; record the YES. **Medical disclosure** — the conditions that drive postponement or a physician clearance are well-known: **diabetes** (slow healing, infection risk), **hemophilia** or other bleeding disorders, **autoimmune disease**, **heart/valve conditions** requiring antibiotic prophylaxis, **pregnancy or breastfeeding**, **blood thinners** (aspirin, warfarin, DOACs), **isotretinoin / Accutane within the past 6 months** (skin fragility), and **active skin conditions** at the tattoo site. **Risks and informed consent** spelled out — pain, bleeding, infection, allergic reaction to ink components, scarring, color migration and fading, design dissatisfaction. **Sterile procedure acknowledgment** — single-use sterile needles opened in the client's presence, surfaces and equipment cleaned per the shop's **bloodborne-pathogens protocol** (OSHA 29 CFR 1910.1030). **Photo release** — three tiers (no photo, tattoo-only with face hidden, full identifying detail). **Aftercare** — written instructions handed over, reviewed verbally, and acknowledged on the form. **Retention** — keep per state/local health-department rules, commonly **2 to 7 years**, and store the form with the ink lot/batch numbers and the cleaning log so a state inspector can reconstruct the procedure from a single client file. The shop's right to **refuse service** for unverifiable age, intoxication, or a medical condition that has not been cleared is a feature, not a bug — preserve it explicitly on the form.
When to use it
- Every tattoo procedure — first session and each subsequent session.
- Pre-procedure intake before stencil placement.
- Photo-release decision per session.
- Medical-condition disclosure for postponement or physician-clearance decisions.
What to include
- Client identity and government-ID last 4 (age verification).
- Design, placement, size, color spec, final stencil approval.
- Allergies, conditions, medications, alcohol/drug use in past 24 hours, recent tattoo at site.
- Risk disclosure and sterile-procedure acknowledgment.
- Photo release.
- Aftercare acknowledgment.
- Client and artist signatures.