Consent Form

Pistol Pete's Tattoo Shop

Name: Email Address:Phone:Date you will be receiving the tattoo:What time will you be receiving the tattoo?: Your Address:

City:

State:

Zip / Postal Code

Country:

Drivers License Or ID Number:Date Of Birth:Age:Please answer the following questions:Have you had Jaundice in the past year?Have you had Hepatitis in the past year?Are you pregnant?Are you nursing a child?Do you have any medical problems? Please explain below if yes.Are you on any medicine? Please explain below if yes.Please check you agree to the below terms:You are hereby notified to the risk associated with receiving a tattoo, which include possible discomfort, pain, and/or the risk of infection, as well as the possibility of allergic reactions to the pigment or other materials used. In case of infection please seek out necessary medical attention and please notify Pistol Pete’s Tattoos @ 806-318-8972 and the Texas State Health Department @ 888-839-6676By signing below, I certify that I am not under the influence of alcohol or any mind altering drugs, and exacted the above information truthfully to the best of my knowledge, I also hereby release Pistol Pete’s Tattoos and its agents from any liability written or implied….Print your signature into the box below:Date:

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