Let’s work togetherClient Intake Form for Aubreigh Lynn Full Legal Name * First Name Last Name Preferred Name (if applicable) First Name Last Name Preferred Pronouns (if applicable) Date of Birth * MM DD YYYY Your Current Age * Your Phone Number * Country (###) ### #### Email * Your Current Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Name * Emergency Contact Phone Number * Country (###) ### #### Emergency Contact Relationship * *All clients must present a valid, government-issued photo ID at their appointment. If you do not bring a valid ID, you will not be tattooed. *CLIENTS UNDER 18: Tattooing of Minors Policy: Toothpick requires all clients under 18 to: • Be accompanied in person by a legal guardian • Have the guardian complete this form in person (web form submissions not accepted) • Present valid photo IDs for both client and guardian • Present an original or certified copy of the minor’s birth certificate • Ensure the guardian remains present during the entire tattoo procedure. We do not tattoo clients under the age of 16. Any falsification will result in immediate cancellation and possible legal action. MEDICAL HISTORY: Please answer honestly. This information helps ensure your safety. Have you ever been diagnosed with or currently have any of the following? (If unsure, please ask your doctor before proceeding.) * Please select all that apply: Diabetes Hemophilia or blood clotting disorders HIV/AIDS or Hepatitis (B or C) Seizure disorder or epilepsy Heart condition or pacemaker High or low blood pressure Skin conditions (eczema, psoriasis, keloids, etc.) Allergies to latex, adhesives, or metals Immune system disorders or immunosuppressants History of fainting or dizziness Pregnancy or breastfeeding History of MRSA or staph infections Current or recent use of antibiotics, Accutane, blood thinners, HRT or steroids History of hypertrophic or keloid scarring Other health concerns or relevant medications NONE OF THESE APPLY If you selected any of the medical conditions above, please explain further below: Please read and acknowledge each of the following by clicking each statement: * I understand that tattooing is a permanent procedure and that removal may be costly, painful, and incomplete. * I understand that tattoos may cause allergic reactions, scarring, swelling, infection, and other complications. * I understand that proper aftercare is critical and that failure to follow instructions may cause healing issues or infection. * I understand that body placement, skin type, or personal health may affect the longevity and appearance of the tattoo. * I understand that hands, fingers, feet, lips, and other high-motion areas may fade, blur, or require touch-ups over time. * I release Toothpick and the artist from liability for any complications that arise due to my personal health or actions. * I confirm that I am not under the influence of alcohol, narcotics, or blood-thinning medications at the time of my appointment. * I give full consent to be tattooed by an artist at Toothpick and understand that final design approval is my responsibility. * I understand that tattoo procedures will not be performed over raised moles, birthmarks, or open wounds. * I agree to present valid photo identification at the time of my appointment and understand I may be turned away without it. PHOTOGRAPHY/VIDEOGRAPHY CONSENT * I consent to photographs being taken of my tattoo and procedure for documentation and promotional purposes. I do NOT consent to photography. By signing below, I affirm that all the above information is true to the best of my knowledge. I understand the nature of the procedure, the associated risks, and the policies of Toothpick. I release Toothpick, its owners, and its artists from liability for unforeseen complications. Electronic Signature Agreement By typing your full legal name below, you acknowledge and agree that this action constitutes your electronic signature and is legally binding in the same manner as a handwritten signature. You affirm that all information provided in this form is true and complete to the best of your knowledge, and you accept all risks and responsibilities outlined above. Your Full Legal Name * Date * MM DD YYYY Thank you!
