Full Legal Name *

First Name

Last Name

Preferred Name (if applicable)

First Name

Last Name

Date of Birth *

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Your Phone Number *

Country

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Your Current Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Phone Number *

Country

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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

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.

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I understand that tattoos may cause allergic reactions, scarring, swelling, infection, and other complications.

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I understand that proper aftercare is critical and that failure to follow instructions may cause healing issues or infection.

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I understand that body placement, skin type, or personal health may affect the longevity and appearance of the tattoo.

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I understand that hands, fingers, feet, lips, and other high-motion areas may fade, blur, or require touch-ups over time.

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I release Toothpick and the artist from liability for any complications that arise due to my personal health or actions.

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I confirm that I am not under the influence of alcohol, narcotics, or blood-thinning medications at the time of my appointment.

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I give full consent to be tattooed by an artist at Toothpick and understand that final design approval is my responsibility.

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I understand that tattoo procedures will not be performed over raised moles, birthmarks, or open wounds.

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I agree to present valid photo identification at the time of my appointment and understand I may be turned away without it.

Date *

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