SamaelDire Tattoo Consent Form
Select artist:
Today's Date:
Sun Sep 14 2025 02:05
Practitioner:
*
-- Select --
Samuel Dire
Other
Please read carefully and answer.
Do you have any of the following medical conditions ?
*
Diabetes
HIV/AIDS
Hepatitis B
Hepatitis C
Haemophilia
Autoimmune/immunosuppressive disorder
Congenital heart disease
Epilepsy
Severe allergies
Narcolepsy
Tuberculosis
Do you have any conditions that affect your skin ?
*
Eczema
Psoriasis
Keloid scarring
EDS / hypermobility
Scleroderma
Active vitiligo
Lichen planus
Sarcoidosis
Pre-existing scarring
Other
Y
N
Are you AT RISK of having HIV or hepatitis B/C?
*
Please inform me if you have recently potentially been exposed to either and have not been tested and/or treated.
If you do not know the HIV/hep status of people you have recently been involved with or shared needles with, you are at risk, so please tell me.
If you're unsure just check "yes" and we can have a chat about it !
Are you on any of the following medications ?
*
Blood thinners
Immunosuppressive medications
Acne medication
Antibiotics
Anti-rejection medication
Y
N
Are you sensitive to any soaps or disinfectants ?
*
Y
N
Are you pregnant or breastfeeding ?
*
Y
N
Anything else ?
Do you have any other conditions/illnesses/difficulties that may impact the tattooing and/or healing process?
If yes, please specify.
Details:
Photography
I release all rights to any photographs taken of me and the tattoo and give consent in advance to their reproduction in print or electronic form.
Do you agree to the terms and conditions stated below ?
*
I acknowledge that I have been given full opportunity to ask any and all questions I may have had about getting tattooed and am fully satisfied with the answers.
I agree to release and forever discharge and hold harmless the tattoo artist from any and all claims, damages, or legal actions arising from or connected in any way with my tattoo and procedures used to apply my tattoo.
I understand that it is not reasonably possible for the tattoo artist to know whether I might have an allergic reaction to any of the pigments or other products used during my tattoo, and I accept the risk that a reaction may occur.
I understand that if I have chosen a pre-made flash design, that the design may be used by the artist in advertising and merchandise in the future.
I acknowledge that the artist is not responsible for the spelling, meaning, symbols, or text that I have provided to them, and that I have checked and fully agreed to the design.
I understand that variation in colour and design between my chosen tattoo and the final result once applied to the skin may occur. I also understand that over time the colour and clarity of my tattoo will fade due to sun exposure and the natural dispersion of pigment under the skin.
I understand that a tattoo is a permanent change to my body that can only be removed via laser or surgical means which can be expensive and/or disfiguring, and may not restore my appearance to it's state prior to receiving the tattoo.
I have been given instructions on how to care for my tattoo correctly and I will follow them. I also understand that the tattoo becoming infected is possible, particularly if I do not follow the care instructions provided. If my own negligence causes touch up work to be necessary, I agree that the work will be done at my own expense.
I acknowledge that I am over the age of eighteen years old, and that I am getting this tattoo by my own choice alone whilst sound of mind and not under the influence of drugs, alcohol, or anything impairing me in any way that could affect my judgement in getting this tattoo.
If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.
Client Information
I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement.
Legal Name:
*
Pronouns:
-select-
He/Him
She/Her
They/Them
He/Them
She/Them
He/She
He/She/They
Other
Chosen name:
Date of birth:
*
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Age:
Phone #:
Email:
*
Social Handle:
If you don't mind us tagging you in photos online
Signature:
*
Sign or type signature:
Emergency Contact
If something happens, your emergency contact might need to explain your medical history, allergies, or medications.
Name:
Phone #: