Name * First Name Last Name Date of birth MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email * Verify Email* Date MM DD YYYY Seizures (such as epilepsy)? Yes No Suffers from any heart conditions? Yes No Blood pressure problems? Yes No Haemophilia or any other blood disorder? Yes No HIV or other immune compromising condition? Yes No Hepatitis A, B, C or D? Yes No Suffers from Diabetes or Lupus? Yes No Skin conditions (such as Eczema or Psoriasis)? Yes No Any allergies to latex, plasters, metals, iodine, creams? Yes No Any allergies to latex, plasters, metals, iodine, creams? Yes No Are you prone to fainting or dizzy spells? Yes No Are you taking any blood thinning medication? Yes No Have you consumed any alcohol or drugs in the past 24 hours? Yes No Any known/previous reaction to dye pigments? Yes No Artist Alba Guido Valentina Martina Teo Ollie Guest Artist Price Deposit £50 £100 None You're all set for your tattoo, darling! Just one last thing… Every now and then, I’ll send a sweet little note with studio news or special treats nothing pesky, just Nana things. Yes, please! I love Nana surprises. No, thank you my dear, maybe another time. Thank you! Consent form
