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.
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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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
Covid19 Precautions:
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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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Yes I consent
No I do not consent
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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Yes
No
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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Yes
No
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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Yes
No
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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Yes
No
I understand that the tattoo studio is an inclusive environment which should be treated with respect. Any behaviour deemed remotely inappropriate, towards staff or clients will not be tolerated. This includes refusal to follow our mask/distancing policies. (Our team reserves the right to terminate your appointment at any time if we have a strong belief that this behavior is occurring. This includes cancelling future appointments)
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Yes
No
If you wish to provide clarification, ask me a question or have any requests for accommodations that we can arrrange to make the process more comfortable for you please write them here.
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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Yes
No