Emerald Tattoo Roseville – Piercing Consent Form

Location/Name of Piercing *

How long since you last ate? *

Name *

First

Last

Birthdate *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Emergency Contact Person *

First

Last

Emergency Contact's Phone Number *

Any other medical or skin conditions response here: *

List all medical or skin conditions below, write NA if none

Currently on any medications response *

Enumerate medications, write NA if none

Is there any other information you feel you should provide to the body art practitioner? *

Disclose anything else you feel the artist should know, write NA if none

Email Address *

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ENTER MANAGER'S PASSCODE BELOW *