This form is for customers with an existing booking. For tattoo enquiries please fill out the enquiry form Step 1 of 3 - Client Details 33% Unique IDArtist Name* Noemi Liz Other HiddenArtist Variable* Artist* Tattoo Body Part* Name* First Last Also known as Preferred pronouns Email* Enter Email Confirm Email HiddenFull Name Phone*Are you over 18?* Yes No Is this your first tattoo?* Yes No Date of birth* YYYY dash MM dash DD Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country ID Type*ID CardDriving LicensePassportID Number* Client medical historyDo you currently suffer from, or have you ever suffered from any of the following?Do you have the capacity to make your own informed decisions?* Yes No Heart Condition/Angina* Yes No Description*Blood Pressure Problems* Yes No Description*Epilepsy/Seizures* Yes No Description*Haemophilia/Blood Clotting Disorders* Yes No Description*Blood borne Virus, e.g. Hepatitis B/C or HIV* Yes No Description*Skin Complaints, e.g. psoriasis, eczema, dermatitis* Yes No Description*Diabetes* Yes No Description*Allergic Response, e.g. anaesthetics, jewellery* Yes No Description*Are you prone to fainting attacks?* Yes No Description*Do you regularly take any blood-thinning medicines, e.g. aspirin?* Yes No Description*Do you take any regularly prescribed medication?* Yes No Description*Are you, or could you be pregnant?* Yes No Description*Are you breast feeding?* Yes No Are you Vegan?* Yes No Have you experienced any Covid-19 related symptoms in the past 14 days?* Yes No Description*Have you had the recent onset of a new continuous cough?* Yes No Description*Do you have a high temperature?* Yes No Description*Have you noticed a loss of, or change in, normal sense of taste or smell?* Yes No Description*Have you read and understood the printed guidelines R.E: COVID-19?* Yes No Covid19Description* How did you hear about us?Do you consent for us to film and take pictures for our social media?* Yes No Terms*I agree that it is my responsibility to read this and follow the aftercare advice given until the treatment area is healed. I give consent to the operator to retain the details provided on this form for a minimum period of two years from today. I agree to the Terms of Service Almost there!Hit submit and you will be redirected to digitally sign the consent form
