Becky Donnelly Consent Form

Becky Donnelly Tattoo Consent Form

* Please fill out the consent form on the day of upon arrival to the studio

* ID is required – please bring a form of valid ID with you to your appointment

Consent to Tattoo:

I acknowledge by signing this agreement that I have been given the full opportunity to ask any questions which I might have about obtaining a tattoo and that my questions have been answered to my satisfaction. I acknowledge that it is not reasonably possible to determine whether I might have an allergic reaction to the pigments or process used in my tattoo and I agree to accept the risk that such is possible.

Acknowledgment of Non-Medical Role:

I understand that Becky Donnelly is not a medical professional and does not provide medical advice. Any suggestions offered by Becky Donnelly are based on her experience as a tattoo artist and should not be interpreted as medical advice. I acknowledge that it is my responsibility to seek professional medical advice if needed.

Risks and Aftercare:

I acknowledge that infection is always possible as a result of obtaining a tattoo, particularly in the event that I do not take proper care of my tattoo. I agree to follow all instructions given by Becky concerning the proper care of my tattoo while it is healing. I confirm I do not feel unwell or show any known COVID-19 symptoms and I have not been exposed to anyone who has contracted COVID-19. I acknowledge that obtaining a tattoo whilst my immune system is low may have an adverse effect on healing and will reschedule my appointment should I feel unwell.

I acknowledge that the tattooing process can, in some cases, result in scarring and tattoo photosensitivity and I agree to accept the risk that such is possible.

Permanent Body Modification:

I fully understand that a tattoo is a permanent modification to my body. I acknowledge that Becky Donnelly has made no claims or assurances regarding the possibility of reversing or altering this permanent change.

Agreement:

I fully understand that I must be over 18 to be tattooed. I acknowledge that I have truthfully represented myself to the employees of the studio and that I have today given my correct name, age, medical and contact details.

This is to certify that I, the below named and undersigned, do give my permission to be tattooed and I am fully aware of the process involved and understand the importance of the daily aftercare procedure.

Legal Full Name:

Contact Number:

Email:

Date of Birth:

Preferred Name/Nicknames:

Pronouns (optional):

Please read the following statements carefully. By checking ‘I agree’ at the end, you confirm that you understand and accept the risks and aftercare conditions associated with tattooing / body-art.

Have you suffered from any of the following? If you answer yes to any of the below, please ensure you have consulted a GP before proceeding and make your artist aware by adding details to the section at the end*

Heart Disease/Condition (SELECT BELOW)

Heart Disease/Condition

Eczema (SELECT BELOW)

Eczema

Impetigo (SELECT BELOW)

Impetigo

Blood Disorder (including clotting) (SELECT BELOW)

Blood Disorder (including clotting)

High/Low Blood Pressure (SELECT BELOW)

High/Low Blood Pressure

Seizure (e.g. Epilepsy) (SELECT BELOW)

Seizure (e.g. Epilepsy)

Diabetes (SELECT BELOW)

Diabetes

Hepatitis A, B & C (SELECT BELOW)

Hepatitis A, B & C

Acne (SELECT BELOW)

Acne

Psoriasis (SELECT BELOW)

Psoriasis

Cellulitis (SELECT BELOW)

Cellulitis

Any other skin affecting condition (e.g. EDS, extremely skin sensitivity)
(SELECT BELOW)

Any other skin affecting condition (e.g. EDS, extremely skin sensitivity)

Bulimia (SELECT BELOW)

Bulimia

HIV Infection (SELECT BELOW)

HIV Infection

Allergy (e.g. latex) (SELECT BELOW)

Allergy (e.g. latex)

Are you taking antibiotics (allow at least 7 days after finishing your course of antibiotics before getting tattooed) (SELECT BELOW)

Are you taking antibiotics (allow at least 7 days after finishing your course of antibiotics before getting tattooed)

Do you have a history of fainting? (SELECT BELOW)

Do you have a history of fainting?

Are you undergoing accutane treatment (SELECT BELOW)

Are you undergoing accutane treatment

Are undergoing chemotherapy (SELECT BELOW)

Are undergoing chemotherapy

Do you have difficulty healing wounds or have you had problems with healing / scarring in the past?
(SELECT BELOW)

Do you have difficulty healing wounds or have you had problems with healing / scarring in the past?

Have you had any tattooing or other body-art procedures in the last 6–12 months?
(SELECT BELOW)

Have you had any tattooing or other body-art procedures in the last 6–12 months?

Please use this space to give us any necessary details about the condition you ticked on the previous pages (if any)

Please tick the following to confirm*:

You are NOT under the influence of drugs or alcohol

You are NOT pregnant or Breastfeeding

You are NOT currently taking blood thinning medication

You are NOT displaying any cold symptoms or fighting an existing condition

You ARE feeling well yourself

Placement & Short Description of Tattoo:

Please confirm the following*:

I consent to photos being taken for studio records / portfolio / social media / aftercare reference.

I confirm that I am over 18 years of age.

I confirm I have disclosed all relevant medical history / conditions / medications that might affect healing or safety

I confirm that I have been informed of the risks associated with tattooing / body art (infection, allergic reaction, poor healing, scarring, fading, after-care responsibilities, etc.)

Date of Appointment & Consent Form Signed on:

Becky will explain your aftercare in full at the end of your appointment, accompanied with a leaflet which will be emailed to the above details.*

I understand

Being an inclusive studio, Becky always aims to ensure that everyone’s individual needs are catered for. Please let her know if there is anything I can do to make your appointment as comfortable as possible:

Your Signature:

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