CLIENT INTAKE FORM

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(By including your IG name, you authorize Pretty In Ink to use your photo of your tattoo)


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Photo of the identification


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When did you eat?textrequireddb save
List allergiestextoptionalno save
Medicationstextoptionalno save
Conditions + Contagious diseasetextoptionalno save

CHECK ANY CONDITIONS THAT APPLY TO YOU

DIABETES
EPILEPSY
ASTHMA
HEPATITIS
HIV/AIDS
HEMOPHILIA
HERPES
PREGNANT
HEART CONDITION
ECZEMA/PSORIASIS
SCARRING/KELOID
NURSING
FAINT/DIZZY
INFECTIONS
T.B.
BLOOD THINNERS

CHECK ALL BELOW

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I hereby certify

I hereby certify that to the best of my knowledge this information is correct and all questions are answered to my satisfaction.


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I agree

This is to certify that I am at least 18 years of age.


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I agree

I am no under the influence of alcohol or drugs.


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I understand

I understand there is a possibility of an allergic reaction as well as infection.


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I agree

I agree to follow all instruction concerning the aftercare of my piercing.


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I understand

I understand that there is a chance that I might feel lightheaded, dizzy and/or faint during or after the piercing.


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I agree

I agree to immediately notify the artist in the event I feel lightheaded, dizzy and/or faint during or after the procedure. Failing to do so releases Pretty In Ink and artist of all responsibility.


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I hereby release

I hereby release Pretty In Ink and Jackie Matikas of all responsibility for the said piercing.


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I agree

No refunds.


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I agree

I am not pregnant or nursing.


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I do not suffer

I do not suffer from medical or skin conditions such as, but not limited to: keloid or hypertrophic scarring, psoriasis at the site of the piercing or any open wounds or lesions at the site of the piercing.


Date: 10.07.2020

Time: 3:47 AM

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