Tattoo Consent and Release Form for your appointment Shauna Seligman Name * First Name Last Name Pronouns Birthdate * You must be at least 18 years of age to be tattooed in our shop MM DD YYYY Phone * (###) ### #### Email * Tattoo Design * Placement * Inform your artists of any medical or skin conditions that you may have in the boxes below. If there are any other medical conditions you don't wish to state on this form, please do so verbally with your artist. This information is STRICTLY confidential between you and your artist and ensures everyone's safety in the tattoo process. Accutane/Acne/Skin Medications Allergies ( latex, soap, fragrance, ect.) Blood Thinning Medication Cold Sores/ Fever Blisters Diabetes Eczema Epilepsy Heart Conditions Hemophilia Prone to Passing Out/Fainting Psoriasis Reaction to Tattoo Pigment Reaction to aftercare Second Skin/bandaging Any other issue that you would like to discuss privately with your artist Signature * Signing here acknowledges that you have read and agree to the release information written on this form. Date * MM DD YYYY Thank you for filling out your consent form for your upcoming tattoo appointment.Please eat before coming to your appointment. You are welcome to bring water and snacks.If you have any question or concerns feel free to text me directly at 503-606-6105.Look forward to your appointment