Health form - Rock'n'Roll Tattoo and Piercing

Name

This field is for validation purposes and should be left unchanged.

Your Full Name(Required)

Your Email(Required)

Your phone number(Required)

Date of birth(Required)

Home address(Required)

Side of the body(Required)

Tattoo or Piercing or Laser?(Required)

Operator name(Required)

Do you currently suffer from or have you ever suffered from any of the following? If yes please describe the details

Heart condition/Angina(Required)

Blood pressure problems(Required)

Epilepsy/Seizures(Required)

Haemophilia/Blood clotting disorders(Required)

Blood borne virus e.g. Hepatitis(Required)

Skin Complaints e.g. eczema(Required)

Diabetes(Required)

Allergic Response(Required)

Are you prone to fainting attacks?(Required)

Do your regular take any blood-thining medicines e.g. aspirin(Required)

Do you take any regular prescribed medication?(Required)

Could you be pregnant?(Required)

How did you find about us?(Required)

I declare that the information I have provided on medical history is correct to the best of my knoweldge that I am not currently under influence of drugs or alcohol. I hereby give consent for the procedure detailed above to be carried out by the named operator. I confirm that i have been provided with written information on the potential complication associated with the procedure and i appropriate after care advice for the procedure. I agree that it is my responsibility to read this and follow up the aftercare advice given until the treatment area is healed. Answer Yes or No.

Yes