Consent Form
About
Booking
MINORS
Store
Menu
TOWER CLASSIC TATTOOING
4146 manchester
St. Louis, Mo, 63110
(314)875-9995
BRIGHT BOLD FOREVER
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TOWER CLASSIC TATTOOING
Consent Form
About
Booking
MINORS
Store
Email
*
Name
*
First Name
Last Name
Are you currently or have you ever used medications that contain a controlled substance?
*
yes
no
Have you ever been diagnosed by a medical doctor as to having contracted communicable disease such as Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and/or other blood borne pathogens? If so, when?
*
yes
no
Have you ever been diagnosed by a medical doctor as having allergies?
*
yes
no
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?
*
yes
no
Are you currently under the influence of any illegal substances?
*
yes
no
Are you currently under the influence of an alcoholic beverage?
*
yes
no
Have you been diagnosed with jaundice within the past twelve months?
*
yes
no
Are you currently using any medications that contain blood thinners?
*
yes
no
Are you currently using any medications that weaken the immune system that fights infections?
*
yes
no
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date Of Birth
*
MM
DD
YYYY
Thank you!