Emerald Tattoo Roseville - TATTOO Consent FormBefore you start filling out the form, please take a photo of your ID (to be uploaded on the next few sections).Please enable JavaScript in your browser to complete this form. - Step 1 of 6How did you hear about us? *FacebookGoogleInstagramPosted SignReferralPamphlets/FlyersReturning CustomerOtherReceiving BODY ART from (artist name) *JesseTrevorJohnDrewRalphGuest ArtistHow long since you last ate? *0 - 30 mins ago30 min - 1 hr ago1 - 2 hrs ago2+ hrs agoName *FirstLastAge *0-1819-2425-3031-4041-5051-6061+Birthdate *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone Number *Emergency Contact Person *FirstLastEmergency Contact's Phone Number *NextTattoo Information - Spelling of any word to be tattooed / Brief description of design *Tattoo Information - Location of tattoo on BODY *BackNextClient Record: Check all that apply *DiabetesEpilepsyFainting / DizzinessHeart Conditions / CardiacScarring / KeloidingAllergic Reactions to LatexHaemophiliaHerpesHerpes in the Procedure AreaPregnant / NursingEczema / PsoriasisSkin ConditionsAllergic Reaction to AntibioticsAllergiesCurrently on any medicationHistory of Cardiac Valve DiseaseEver been prescribed antibiotics prior to dental or surgical proceduresAny other medical or skin conditions that may affect the outcome of your procedureNone of these applyAny other medical or skin conditions response here: *List all medical or skin conditions below, write NA if noneCurrently on any medications response *Enumerate medications, write NA if noneIs 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 noneEmail Address *(Sign up for our newsletter to receive our latest deals & specials)BackNextThank you for your response. Please show your phone/tablet to the manager and have your ID ready along with any other documents you might need to show.BackNextENTER MANAGER'S PASSCODE BELOW *BackNextFor MANAGERS ONLY:Have you spoken to client about nursing or pregnancy? *YesNoNot ApplicableImage of ID * Click or drag files to this area to upload. You can upload up to 10 files. Picture of any reference material / sketches done by artist Click or drag files to this area to upload. You can upload up to 5 files. Needle and Tube InfoNeedle 1 Click or drag a file to this area to upload. Needle 2 Click or drag a file to this area to upload. Needle 3 Click or drag a file to this area to upload. Needle 4 Click or drag a file to this area to upload. Needle 5 Click or drag a file to this area to upload. Tube 1 Click or drag a file to this area to upload. Tube 2 Click or drag a file to this area to upload. Tube 3 Click or drag a file to this area to upload. Tube 4 Click or drag a file to this area to upload. Tube 5 Click or drag a file to this area to upload. Submit