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Client Information

Full Name: ____________________________________________

Date of Birth (MM/DD/YYYY): _____________________________

Age: ________

Phone Number: _________________________________________

Email Address: __________________________________________

Address: ______________________________________________

City, State, ZIP: _________________________________________

Parent/Legal Guardian Information (For Clients Under 18)

Parent/Guardian Full Name: ________________________________

Relationship to Client: ____________________________________

Phone Number: _________________________________________

Government-Issued ID Type & Number: ______________________

Signature of Parent/Guardian: _____________________________      Date: ____________

Medical Disclosure

Do you have any of the following conditions? (Check all that apply):

[ ] Diabetes
[ ] Heart Condition
[ ] Blood Disorders
[ ] Skin Conditions
[ ] Allergies
[ ] Epilepsy
[ ] Other: ___________________________

Are you currently pregnant or nursing? [ ] Yes    [ ] No

Are you under the influence of drugs or alcohol? [ ] Yes    [ ] No

Are you currently taking any medications? If yes, list them: ___________________________

Procedure Details

Tattoo / Piercing Description: __________________________________

Placement on Body: _________________________________________

Artist’s Name: _____________________________________________

Date of Procedure: _________________________________________

Client Consent & Release

I acknowledge that I have truthfully represented that I am at least 18 years of age or have my parent/guardian present and consenting to the procedure. I understand that there are risks associated with tattooing and piercing, including infection, scarring, and allergic reactions. I confirm that the information provided is accurate and complete. I release The Kingdom Tattoos, its artists, and affiliates from any liabilities, claims, or damages that may result from the procedure.

Client Signature: ___________________________    Date: ____________

Artist Signature: ___________________________    Date: ____________