Client Information

First name

Last name

Birthday

Age

Phone

Email

Multi-line address

Country/Region

Address

City

Zip / Postal code

Pre-Procedure Questionnaire

Are you under the influence of drugs or alcohol?

Yes

No

Are you pregnant or nursing?

Yes

No

Do you have any communicable disease?

Yes

No

Do you have any skin conditions?

Yes

No

Allergies/Skin conditions (topical solutions, lidocaine, medications, latex, etc.)

Acknowledgment and Waiver

I understand that this procedure is a permanent change to my skin and body.

I allow my tattoo to be photographed and be used for Bruno Dalfito Tattoo Shop portifolio showcased.

I acknowledge that Bruno Dalfito Tattoo Shop does not offer refund.

I agree that Bruno Dalfito Tattoo Shop does not have a way of identifying if I am allergic to the elements or ingredients that will be used for my tattoo.

I indemnify and hold harmless Dopamine Tattoo LLC and Bruno Dalfito Tattoo Shop against any claims, expenses, damages and liabilities.

I confirm that the information I provided in this document is accurate and true.

Singed Date

Client Signature.

Signature field is empty.

Photo of the client's ID