Consent form · Maya Johnson
Half day, Sat Oct 10, 11am Reviewed Checked in 3:29pm
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Health flags (1): read before you start
Allergies: check before starting
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Checked in Sat Oct 10, 3:29pm
Form reviewed Sat Oct 10, 3:29pm. ID checked Sat Oct 10, 3:29pm.
ID photo
Name on the formMaya Johnson
Date of birth on the form1992-04-18
Check the photo and the date of birth against the person and their card. Opening it is logged.
About you
Full legal nameMaya Johnson
Date of birth1992-04-18
Mobile phone519-555-0170
Emailmaya.johnson@example.com
Emergency contact: nameSam Johnson
Emergency contact: how they're related to youSibling
Emergency contact: phone519-555-0171
Your health
Are you pregnant, or breastfeeding?No
Do you take blood thinners, or have you taken aspirin or ibuprofen in the last 24 hours?No
Do you have a bleeding or clotting disorder?No
Do you have diabetes?No
Do you have a heart condition or a pacemaker, or high or low blood pressure?No
Do you have epilepsy, or have you had seizures?No
Have you ever fainted during a tattoo, piercing, injection or blood test?No
Do you have an immune condition, or treatment that weakens your immune system?No
Do you have hepatitis B or C, HIV, or another infection that can pass through blood?No
Is there any skin condition where the tattoo will go?No
Do you form keloids or raised (hypertrophic) scars?No
Is the skin where the tattoo will go sunburnt or peeling, or likely to be on the day?No
Are you allergic to latex?No
Any other allergies?Yes: Sticking plaster leaves a rash
Are you taking any medication, prescription or over the counter?No
Have you taken isotretinoin (Accutane, Epuris, Clarus) in the last 12 months?No
Have you had alcohol or recreational drugs in the last 24 hours, or will you before your session?No
Anything else about your health Vik should know?No answer
Your acknowledgements
I understand a tattoo is permanent. Removing or covering it later is expensive, can be painful and may not fully work.✓ Agreed
I've seen and approved the final design, including the spelling and wording, the size and where it goes on my body. Mistakes in anything I approved are my responsibility.✓ Agreed
I understand colours and shading look different on every skin, soften as the tattoo heals and can fade over time (especially in the sun), and that a touch-up may be needed.✓ Agreed
I understand tattooing breaks the skin and carries risks, including infection, an allergic reaction to pigment, scarring and slow healing, and that following the aftercare is my responsibility once I leave. If I see signs of infection I'll see a doctor and let Vik know.✓ Agreed
I'll follow the aftercare instructions Vik gives me.✓ Agreed
I understand my deposit holds my session and comes off the final price. If I cancel or move the session with less than 48 hours' notice, or don't show up, the deposit is kept.✓ Agreed
I won't come to my session under the influence of alcohol or drugs. If I do, Vik won't tattoo me and the deposit is kept.✓ Agreed
My answers are true and complete, and I'll tell Vik before he starts if anything has changed. I understand he relies on them to decide whether it's safe to tattoo me.✓ Agreed
I'm 18 or older, or I'm under 18 and my parent or legal guardian consents below, will come to the session and will show Vik their photo ID.✓ Agreed
I release Vik and CozyInkz Tattoo Co. from claims for the normal risks and results described above, and for anything caused by information I didn't give or by not following the aftercare. This doesn't take away any right that the law says can't be given up.✓ Agreed
Can Vik photograph your tattoo for his portfolio and social media?Yes
Signature
Typed nameMaya Johnson
SignedSat Oct 10, 3:29pm
Form version2026-10-08.1
