Southgate SG Tattoo & Piercing Studio
Consent Form
All fields marked with * are required and must be filled.
Are you completing this consent form for yourself (tattoo/piercing) or on behalf of a minor (for piercings only)? * MyselfOther
Procedure * TattooPiercing
Name *
Last Name
Age *
Date of Birth *
Phone Number *
Email
Address
How did you hear about Southgate SG Tattoo & Piercing Studio? * GoogleStudio Social MediaArtist's Social MediaInkpayTattooDoLocalFriend RecommendedOther
Are you under the influence of drugs or alcohol? * YesNo
FEMALE ONLY: Are you pregnant or nursing? Any other gender please select’No’. * YesNo
Do you have a communicable disease? * YesNo
Are you prone to dizziness or fainting? * YesNo
Do you have any skin conditions? * YesNo
Please tell about your medical history (e.g. DIabetes, Cardiovascular Disease, Epilepsy, Blood-related disease, Blood pressure etc.) *
01 I understand that this procedure is a permanent change to my skin and body.I understand that this procedure is a permanent change to my skin and body. *
02 I allow my tattoo/piercing to be photographed and used for SG Studio's portfolio showcased.
03 I agree that SG Studio does not have means of identifying if I am allergic to the elements or ingredients that will be used for my tattoo/piercing.*
04 I understand that I will need to take care of the tattoo/piercing by following the instructions given to me by a member of our team.*
05 I understand that I might get an infection if I don't follow the instructions given to me in regards to taking good care of my tattoo/piercing.*
06 I hold harmless and indemnify Southgate SG Tattoo & Piercing Studio against any claims, expenses, damages, and liabilities.*
07 I confirm that the information I provided in this document is accurate and true.*
Signed Date *
Client Signature Clear
