(This will be sent to you with your confirmation email. Please print it and bring it with you to your appointment.)

 PLEASE COMPLETE THE FOLLOWING FOR YOUR TATTOO TO BE CARRIED OUT BY JO CHASTNEY, AND INFORM THEM IF YOU TICK ANY BOXES.

Do you suffer from any skin conditions?
(Eczema, Psoriasis)

Do you suffer from circulation disorders?
(Heart disorder, High/Low blood pressure, Haemophilia)

Are you pregnant or breastfeeding?

Do you have Epilepsy?

Do you have Diabetes?

Do you have an Autoimmune disease?

Are you on any medication?

Do you have any allergies?

Have you consumed any drugs or alcohol in the last 24 hours?

Do you have HIV, Hepatitis B/C?

Do you have any other medical condition I should be aware of?

(Potential risks of getting a tattoo: Scarring, blood poisoning, localised infection, allergic reaction, localised swelling.)

Full name _____________________  Tel no ____________________

Address _____________________________________________________

D.O.B ___/___/______  ID No __________________________________

Emergency Contact and number ______________________________

I have answered this form truthfully to the best of my knowledge. I understand that there is a possibility that my tattoo could become infected if I do not look after it.
I agree that any touch up work needed, due to my own negligence, will be carried out at my own expense.
I also understand that a tattoo is a permanent change to my appearance and allow my tattooist to carry out the tattoo.
Sign _________________________________________

Date ________________________________________