Tattooing/Body Piercing Consent Form
Name of Premises:
Address & Tel No of Premises:
Name of Practitioner (print):
Name of Client (print):
Address & Tel No of client:
Age of Client and DOB:
Age ID of Client Seen:
Yes / No
Type of Procedure:
Tattoo / Body Piercing
Description:
Site of Procedure and design if
applicable):
Type of Jewellery Used (as
applicable):
Medical History of Client
Note: Medical advice should be
sought in any case of doubt as to
whether procedure is suitable.
Yes
(TICK)
No
(TICK)
Actions: if any question answered ‘Yes’
procedure to be reviewed and medical advice
to be obtained.
(Attach separate sheet if necessary)
Suffers from any heart
conditions (e.g. prosthetic heart
valve/ heart valve disease/
angina/ blood pressure
problems)?
Suffers from epilepsy?
If Yes, how controlled?
Suffers from haemophilia/other
clotting disorders?
Suffers from any known blood
borne virus (e.g. Hep B, Hep C,
Hep D, HIV)?
Suffers from diabetes or lupus?
Suffers from any problems with
skin healing in the past, e.g.
psoriasis, eczema?
Suffers from any ‘lumpy’ raised
scars (keloid scars)?
Suffers from any known allergic
responses eg plasters/creams/
metals/iodine/shellfish/latex/food
-stuffs/other? Indicate which:
Takes any prescribed medication
regularly (especially any
anticoagulants such as Warfarin
or high dose asprin; any
immuno-suppressants such as
steroids)?
If Yes, list which:
Is the client pregnant?
Prone to ‘fainting attacks’?
If yes, state reason:
Tattoo only: Any known/previous
reaction to dye pigments?
Piercing only: Any previous
piercings at proposed site?
Any other relevant information?
Declaration:
‘I declare that I give my full consent to tattooing/ body piercing (delete as appropriate)
being carried out by the aforementioned practitioner. I confirm that potential
complications, (eg infection, swelling (for both tattooing and piercing), gum/tooth
damage, jewellery migration/embedding) for the procedure undertaken and aftercare
instructions have been explained to me. A written aftercare advice sheet containing
more detailed information has been given to me and I agree that it is my responsibility
to read this and follow the instructions on it, until the site has healed.
I confirm that the above information provided by me for this consent form is correct to
the best of my knowledge, that I am over the age of consent for this procedure (as
explained to me by the practitioner) and that I am not currently under the influence of
alcohol or drugs.’
Signature of Client:
Date:
Name of Client (Print):
Contact Details of Client:
Signature of Practitioner:
Date:
Appropriate aftercare
information given for Tattooing
and/or Body Piercing:
Yes No Please tick appropriate box
PARENTAL CONSENT (as applicable for piercing):
‘I consent that all of the intended procedure has been explained to me and that the information
provided by me is correct to the best of my knowledge. I hereby consent to my child (named
above) having the body piercing’
Signature of Parent:
Date:
Name of Parent (Print):
Contact Details of Parent:
Signature of Practitioner:
Date:
Appropriate aftercare
information given for Body
Piercing:
Yes No Please tick appropriate box
