Prescription Form

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General Information

This treatment is only for the person named below

Full Name

Phone

Email

Date of Birth

Allergies

Please include any allergies to dyes, vitamins, herbs, food, supplements, prescription medications, or over-the-counter medicines (e.g. antibiotics, allergy medications), or anything else.

I, hereby declare that I wish to use a tattoo numbing cream during my upcoming tattoo session. I understand that the use of such creams may contain certain ingredients that could potentially trigger allergic reactions or complications, and I acknowledge the importance of disclosing any pertinent medical information to ensure my safety and well-being during the tattooing process.

In accordance with this, I affirm below by checking that I have or do not have allergic reactions to usage of the following substances:

Lanolin

YES, I'm allergic

NO

Novocaine

YES, I'm allergic

NO

Lidocaine

YES, I'm allergic

NO

Benzocaine

YES, I'm allergic

NO

Tetracaine

YES, I'm allergic

NO

Phenylephrine

YES, I'm allergic

NO

Prilocaine Hydrochloride

YES, I'm allergic

NO

Please list any allergies to dyes, vitamins, herbs, food, supplements, prescription medications, or over-the-counter medicines (e.g. antibiotics, allergy medications), or anything else.

Please explain if you have had any surgeries or hospitalizations, please provide in list format the dates and reasons for your surgeries or hospital stays.

Medical History

In accordance with this, I affirm below by checking that I do or do not have a history of any of the following medical conditions that could pose risks or complications during the tattooing process:

High Blood Pressure

YES

NO

Pacemaker or Stent

YES

NO

Blood Clotting Disorders

YES

NO

Heart palpitations

YES

NO

Autoimmune disorders

YES

NO

Seizures

YES

NO

Stroke

YES

NO

Please list any other conditions you have previously been diagnosed with below and or any other medical conditions you treat with medications and the medications you take:

I understand that failure to disclose accurate medical information could potentially result in adverse effects during or after the tattoo procedure. Therefore, I take full responsibility for providing complete and truthful information regarding my medical history to ensure a safe and successful tattoo experience.

I release The Cream Tattoo Supply Company, the Tattoo artist, Tattoo shop and any associated personnel from any liability related to adverse reactions or complications that may arise due to my failure to disclose relevant medical information or due to my allergic reactions to the aforementioned substances.

I certify that all the information provided herein is true and accurate to the best of my knowledge.

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General Information

Allergies

In accordance with this, I affirm below by checking that I have or do not have allergic reactions to usage of the following substances:

Medical History

In accordance with this, I affirm below by checking that I do or do not have a history of any of the following medical conditions that could pose risks or complications during the tattooing process:

I certify that all the information provided herein is true and accurate to the best of my knowledge.

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