| 61 Bridge Street | Kington | HR5 3DJ

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Health Screening Questionnaire, Design Proof & Informed Consent Form

To be filled out correctly and honestly in block capitals.

Full Name: ______________________________________________________________________________________

DOB: ____ / ____ / ____ Current Age: _____ Proof of ID Type: _______________________________________

Address: _______________________________________________________________________________________

___________________________________________________ Telephone: _________________________________

Email

Name of Premises:

Address of Premises:

Name of Practitioner:

Type of Procedure:

Site of Procedure:

Type of Jewellery used:

Date of Procedure:

GDPR: Unicorn Stabs respect your privacy, are legally required to store the information provided, and do so under

strict GDPR compliant guidelines. Unicorn Stabs do not share personal details with third parties.

The contact information supplied may be used in the future to send occasional email notifications (Never postal), or

text message to keep our clients informed about (for eg) their appointment, potential cancellations, last minute

bookings, offers and events, but we expect this to be infrequent (Once a month or less). Email notifications will offer

you the option to opt out manually with each message, and you are free to do so at anytime. If you do not wish to

receive contact at all from Unicorn Stabs, please tick this box □

We may also wish to contact you via Facebook to ask for a review, or let you know of possible changes to your

appointment(s). If you do not wish to receive this kind of contact at all from us, please tick this box □

Photo Consent: With permission, we may also post photo‘s of our work on your body once completed on social

media, our website, or in a portfolio. Unless specifically requested, we do not include an image of your face so as to

maintain anonymity and protect client identity, and we do not share personal information publicaly. If you do not

wish to allow this, please tick this box □

| 61 Bridge Street | Kington | HR5 3DJ

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Health Screening Questionnaire

Conditions – Do you suffer from: Yes No Actions

ANY Heart Condition? (Include information about any or all heart conditions including Blood Pressure issues)

Epilepsy or Seizures? (If yes, how is it controlled?)

Haemophilia or other clotting disorders?

Any known blood or fluid born Viruses? (Such as Hep A-D & HIV, Genital Wart, Herpes etc…)

Diabetes or Lupus?

Any Skin Disorders? (Such as Psoriasis, Eczema, Celluliti, Acne, Impetigo etc…)

Keloid Scarring?

Any known allergic responses? (Allergies to plasters / creams / metals / iodine / latex / shellfish / food stuffs / other…?)

Prone to Dizzy spells, Vertigo, Disequilibrium or Fainting?

Are you Pregnant or Breast Feeding?

Takes prescribed medication regularly? (Especially Anticoagulants (Blood thinners), Warfarin, High dose Aspirin, or immune-suppressants such as Steroids?). If yes, which?

Anxiety and/or Depression?

Anorexia and/or Bulimia?

Autoimmune Diseases?

TATTOO ONLY: Any known previous reaction to dye pigments?

PIERCING ONLY: Any previous piercings at proposed site?

Other Conditions? Please give details…

| 61 Bridge Street | Kington | HR5 3DJ

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Declaration: ‘I declare that I give my full consent to tattooing / body piercing being carried out by the aforementioned

practitioner.

I confirm that potential complications (e.g. Infection, Swelling, Gum/Tooth damage, Jewellery Migration/Embedding) for the

procedure have been explained to me, and that I have had every possible opportunity to ask questions, and that all have been

answered to my satisfaction. I declare that I am fully informed and aware of the procedure that I am about to take, and am

freely willing to proceed. I acknowledge that it is not always reasonably possible to determine whether I might have an allergic

reaction.

I confirm that the above information provided by me for this consent form is correct and an honest account of my current health

status to the best of my knowledge, and that I am over that age of consent for this procedure and provided proof as such. I also

confirm that I am not currently under the influence of alcohol or drugs, nor have been for the past 48 hours, and that I have

read, understood and agree to the terms & conditions set out via the Unicorn Stabs website – www.unicornstabs.com.

I confirm that written aftercare advice has been given to me, and I understand that this information is also available on the

Unicorn Stabs website, and I agree that it is my responsibility to read and follow these instructions until the site is healed, and

that if I have further queries, that I am able to contact my practitioner.

I declare that I have discussed and agreed upon design/artwork with my Artist/Practitioner, am confident in their skill set and

am happy to proceed, and that I have proof read and approved any spellings or dates as correct.

I agree to identify and keep indemnified the Practitioner & Studio against all claims and proceedings in respect of any personal

injury or damage caused as a result of the supply of service, and that I am aware of the complaints procedure’.

Print Name:

Signature:

Date:

Parental Consent (Applicable to body piercing):

‘I consent that all of the intended procedure has been explained to me, and that the information provided by me is

correct to the best of my knowledge. I herby consent to my child (Named above) having the procedure’.

Name of Parent:

Address of Parent:

Telephone Number of Parent:

Email Address of Parent:

Signature of Parent:

Date:

Practitioner Signature:

Date:

| 61 Bridge Street | Kington | HR5 3DJ

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Tattoo Design Proof

Included Names & Spelling of names: (Please PRINT in block capitals).

Included Dates:

Included wordage & Spelling: (Or other Alphabetical, Numerical or Symbolic information).

Design Description & Attached Image: (Attach a separate sheet if necessary)

Client Signature:

Practitioner Signature:

Date: