Customer Info Form (Gravity form lives here) - Headless Hands Custom Tattoos

Customer Info Form

Please do not fill out until the day of your appointment.
Date*
MM slash DD slash YYYY
Name*
First Last
Artist Name*
Description of Tattoo*
Location of Tattoo*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Email*
Age*
Date of Birth*
MM slash DD slash YYYY
I am at least 18 years.*
- Agree
- Disagree
DL / ID Number*
How did you hear about us?*

Social media, personal recommendation, etc
Medical
Please Answer the Following Questions: *Answering “yes” to any of these questions does not necessarily preclude the person from receiving a tattoo or piercing.
Has a physician told you that you have hepatitis?*
- Yes
- No
Have you been jaundice (yellowing of skin or eyes) in the previous 10 days?*
- Yes
- No
Are you prone to fainting?*
- Yes
- No
Do you have diabetes?*
- Yes
- No
Do you have difficulty-stopped breathing?*
- Yes
- No
Do you take a blood thinner?*
- Yes
- No
Do you have heart related problems?*
- Yes
- No
Do you have high blood pressure?*
- Yes
- No
Do you have any known allergies?*
- Yes
- No
If so, please list them:*

Allergies: E.g. cats, penicillin, seasonal outdoor allergies, avocados, etc.
Are you taking any medications?*
- Yes
- No
If so, please list them:*

Medications: E.g. Advil, Allegra, Quaaludes
Have you consumed any alcoholic beverages in the last 8 hours?*
- Yes
- No
Have you consumed a full meal within the last 2 hours?*
- Yes
- No
Have you consumed any anticoagulants (aspirin, ibuprofen, etc.) in the last 24 hours?*
- Yes
- No
Are you pregnant?*
- Yes
- No
Are you nursing?*
- Yes
- No
Do you have any other conditions that might affect the healing of this tattoo/body piercing?*
- Yes
- No
I am not a hemophiliac (bleeder).*
- Agree
I do not take blood thinners.*
- Agree
I do not have a heart condition.*
- Agree
I am not pregnant or nursing.*
- Agree
I am not under the influence of drugs or alcohol.*
- Agree
To my knowledge I don’t have any physical, mental or medical impairment, condition, or disability which might affect my wellbeing as a direct or indirect result of my decision to have any tattoo- related work performed on me.*
- Agree
I agree to follow all instructions concerning the care of my tattoo while it is healing and afterward.*
- Agree
I agree that any touch-up work needed, due to my own negligence, will be done at my own expense.*
- Agree
I understand that if my skin color is darker, the colors will not appear as bright as they do on light skin.*
- Agree
Being of sound mind and body, I hereby release any and all persons representing Headless Hands Custom Tattoos inc. from all responsibility, now and in perpetuity.*
- Agree
I accept any and all responsibility myself for any consequences that might stem from my decision to have any tattoo-related work done by a representative of Headless Hands Custom Tattoos inc.*
- Agree
I agree for myself, my heirs, assigns, and legal representatives to hold harmless from all damages, actions, causes of action, claim judgments, costs of litigation, attorney’s fees, and all other costs and expenses which might arise from my decision to have any tattoo-related work done by a representative of Headless Hands Custom Tattoos inc.*
- Agree
I agree to leave the premises of Headless Hands Custom Tattoos inc., or any other establishment where Headless Hands Custom Tattoos inc. is engaged in business, promptly upon request, for any reason whatsoever, by any agent or employee of Headless Hands Custom Tattoos inc.*
- Agree
I agree to pay for any and all damages or injuries to any and all persons and property belonging to Headless Hands Custom Tattoos inc., or any other person to whom Headless Hands Custom Tattoos inc. and representatives may become liable contractually or by operation of law, caused by, or resulting from my decision to have any tattoo-related work done by a representative of Headless Hands Custom Tattoos inc.*
- Agree
I agree that these waivers also pertain to and are designed to protect any and all establishments where Headless Hands Custom Tattoos inc. conducts business.*
- Agree
I agree to receive email from Headless Hands Custom Tattoos inc. I understand that Headless Hands Custom Tattoos inc. will not share my information in any way, except as required by law, with any 3rd parties. Artist may require payment in advance of process.*
- Agree
All clients must present valid ID, and agree to being photographed by Headless Hands Custom Tattoos inc. artist or representative.*
- Agree
Photos will be used in portfolios and as promotion for Headless Hands Custom Tattoos inc. I agree to release my pictures for any use by Headless Hands Custom Tattoos inc.*
- Agree
I AGREE THIS SHOP HAS A NO REFUND POLICY ON TATTOOS, PIERCINGS AND/OR RETAIL SALES AND I WILL NOT ASK FOR A REFUND FOR ANY REASON WHATSOEVER.*
- Agree
I hereby give consent to my selected tattoo artist of Headless Hands Custom Tattoos inc. to perform a tattoo/body piercing, and in consideration of doing so, I hereby release my selected tattoo artist and Headless Hands Custom Tattoos inc. from all manner of liabilities, claims, actions, and demands in law, or in equity, which I or my heirs might now or hereafter by reason of complying with my request of a tattoo or body piercing. I fully understand that any employee or representative of Headless Hands CustomTattoos Inc., when performing a tattoo or body piercing, does not act in the capacity as a medical professional. The suggestions made by any employee or agent of Headless Hands CustomTattoos Inc. are just suggestions. They are not to be construed as, or substituted for advice from a medical professional. I understand that the tattoo or body piercing will be performed using appropriate techniques, instruments, and pigments. I also understand that infections can occur due to lack of proper hygiene and/or pigment sensitivities. To ensure proper healing of my tattoo or body piercing, I agree to follow the written and verbal aftercare instructions that will be provided, until healing is complete. I understand that a tattoo or body piercing may take several weeks to heal properly. I understand that I am making a permanent change to my body, and no claims about the possibility of reversing these changes have been made or implied by Headless Hands Custom Tattoos Inc. or any of its employees, representatives or agents. I have read and understood each of the above paragraphs.*
- Agree
For Minors:
Minor Client Full Name*
Parent or Court-Appointed Guardian*
First Last

Customer Info Form

Please do not fill out until the day of your appointment.

Medical

For Minors: