Full Legal Name
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Must match your Government issued Photo ID as required by public health. Please bring your ID to your appointment, no exceptions.
First Name
Last Name
Date of Birth
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You must be 18+ to get tattooed at Coach House Collective.
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DD
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Phone number
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(###)
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Address
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Email Address
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Is this your first tattoo?
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Yes
No
Do you have any heart conditions?
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No I do not
High Blood Pressure
Low Blood Pressure
Angina
Other - please clarify below.
Do you have Epilepsy?
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No I do not
Yes, but it is managed and stable
Yes, but my condition is not stable
Have you ever experienced any of the following issues with your skin?
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Do you have any blood disorders, diseases or viruses including:
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Do you have any other health concerns your artist should be aware of ?
Are you pregnant or nursing?
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No
Yes
Have you tested positive for Covid19, travelled outside Canada in the last 14 days or been in contact with anyone who suspected or known to have contracted Covid19?
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Yes
No
Are you prone to fainting, dizziness or light headedness?
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Yes
No
Are you currently under the influence of any drugs or alcohol?
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Yes
No
I understand the process of getting tattooed and feel comfortable that I have asked my artist any questions I may have. I am aware that feeling dizzy or fainting during the tattoo procedure is not uncommon and I consent for my artist, or other staff present, to assist me if I lose consciousness with no liability to the staff or persons involved.
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I understand that I will receive detailed aftercare instructions after my tattoo is complete. I know that once I leave the studio my new tattoo is my responsibility and I understand the potential for infection. I am aware of how to care for my new tattoo. Any damage to my body as a direct result of negligence is my responsibility, including paying for a touch up if necessary.
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I understand that tattoos are a permanent procedure, and if I change my mind that removal will not be in any way paid for or facilitated by the studio. To the best of my knowledge I have no medical or mental impairments which could directly or indirectly influence my decision making. I am freely making the decision to get this tattoo, with no feeling of coercion by outside parties or groups.
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I acknowledge it is not reasonably possible for the representatives and employees of this tattoo shop to determine whether I might have an allergic reaction to the pigments or processes used in my tattoo, and I agree to accept the risk that such a reaction is possible.
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I realize that variations in color and design may exist between any tattoo as selected by me and as ultimately applied to my body, including changes in healed color, line thickness, natural fading etc.
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I understand that if I have any skin treatments, laser hair removal, plastic surgery, hair dye on head tattoos, sunburn or other skin altering procedures, it may result in adverse changes to my tattoo.
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I understand that the tattoo studio is an inclusive environment which should be treated with respect. Any behavior deemed remotely inappropriate, towards staff or clients will not be tolerated. (Our team reserves the right to terminate your appointment at any time if we have a strong belief that this behavior is occurring.)
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I approve my artist to take photos of the tattoo and share photos of your tattoo on social media. This is not mandatory.
I confirm that all the statements above are true to the best of my knowledge and that I am over the legal age of consent for this procedure that I am agreeing to.
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If you wish to provide clarification on your answers above, ask a question to your artist or if you have any other information that you feel your artist should know please write it here.
Needle Lot Numbers
For Internal Use Only. Please do not write in this section.