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The Carried Flame Tattoo Studio LLC

30148 W Dam Access Road Warsaw, Mo 65355

(660) 900-2015

Tattoo Medical Questionnaire 

 

 

CONSENT OF APPLICATION OF TATTOO AND RELEASE AND WAIVER OF ALL CLAIMS

June 17, 2026 I

 acknowledge by signing this document that I have been given full opportunity to ask any and all questions which I might have about obtaining of a tattoo. I specifically acknowledge that I have been advised of the facts and matters set forth below, and I agree as follows: 

I acknowledge that I am at least 18 years of age.

I Agree

 I acknowledge that I am not pregnant or nursing.

I Agree

I acknowledge that I am free from Jaundice, Hepatitis, or other Communicable Diseases.

I Agree

I acknowledge that I am not under the influence of drugs or alcohol and I am voluntarily submitting to be tattooed without duress or coercion.

I Agree

I acknowledge receipt of written instructions advising me of proper care of the tattoo.

I Agree

I acknowledge that the tattoo should be considered permanent; that it can only be removed by surgical procedure and that any effective removal may leave permanent scarring or disfigurement.

I Agree

I acknowledge that a tattoo is a permanent change to my appearance and no representations have been made to me as to the ability to later change or remove the tattoo. 

I Agree

I acknowledge that it is not reasonably possible for the representatives of The Carried Flame Tattoo Studio LLC to determine whether I might have an allergic reaction to the dyes, pigments and/or processes used in execution of the tattoo and I agree to accept the risks that such a reaction is possible.

I Agree

I acknowledge that tattoo inks are not FDA approved and health consequences are unknown.

I Agree

 I acknowledge that with tattoos there is always a possibility of getting an infection. Your tattoo should heal in 2 weeks. Refer to provided aftercare sheet for proper care instructions, Expect redness and soreness for the first 1-4 days. 

I Agree

I have not been sick, shown symptoms of sickness or been around any known sick persons in the last 14 days.

I Agree

I hereby grant The Carried Flame Tattoo Studio LLC and its representatives and employees, permission to use and/or publish photographs or videos of myself or my tattoos in print and/or electronically. I understand and agree that these materials will become the property of The Carried Flame Tattoo Studio LLC and will not be returned. I hereby authorize The Carried Flame Tattoo Studio LLC to edit, alter, copy, exhibit, publish, or distribute the photograph or video for purposes of publicizing their work or for any other lawful purpose. In addition, I waive my rights to any compensation arising or related to the use of the photographs or videos. I release and forever discharge The Carried Flame Tattoo Studio LLC from any and all claims arising out of use of the photos or videos for any lawful purpose such as for publicity, illustration, advertising, and Web content.

June 17, 2026

I agree to release and forever discharge and hold harmless The Carried Flame Tattoo Studio LLC and it's contractors, employees, agents and/or representatives from any and all claims, damages, or legal actions arising from or connected in any way with the tattoo or the procedure and/or conduct used to apply said tattoo.

The information I have provided is complete and true to the best of my knowledge.

June 17, 2026

 

First Client's Name
First Name*
Middle Name
Last Name*
Phone*
By checking this box, you agree to receive text message updates from the business who owns this Smartwaiver form. Msg & data rates may apply. Msg frequency is recurring. Reply STOP to opt out.
First Client's Date of Birth*
Date of Birth
Information
Allergic reactions to latex*
No
Yes
Diabetes*
No
Yes
Hemophilia or bleeding disorder*
No
Yes
Scarring/keloiding*
No
Yes
Any risk for blood borne pathogens*
No
Yes
Allergic reactions to antibiotics*
No
Yes
History of herpes infection at the procedure site*
No
Yes
History of heart valve disease*
No
Yes
Do you have any allergies?*
No
Yes
Skin conditions*
No
Yes
Do you use any medications that might affect the healing of the tattoo you wish to receive*
No
Yes
Is there any information that you feel you should provide to the body art practitioner*
No
Yes
Important Health & Allergy Information Please disclose any allergies, medical conditions, sensitivities, medications, or other health concerns that may affect your tattoo procedure. While this waiver collects important health information, it is your responsibility to discuss any allergies, concerns, or special considerations directly with your tattoo artist before the procedure begins. This includes any information you believe may impact your safety, comfort, healing process, or the outcome of your tattoo. If you are unsure whether a condition, medication, or allergy is relevant, please inform your artist prior to your appointment. *
I understand it's my responsibility to speak with my artist.
Who will be doing your tattoo today?
Location on body *
Tattoo Design *
How did you hear about us *
Referral
Social media
Google
Other
First Client's Signature*
Second Client's Name
First Name*
Middle Name
Last Name*
Phone*
Client's Date of Birth*
Date of Birth
Information
Allergic reactions to latex*
No
Yes
Diabetes*
No
Yes
Hemophilia or bleeding disorder*
No
Yes
Scarring/keloiding*
No
Yes
Any risk for blood borne pathogens*
No
Yes
Allergic reactions to antibiotics*
No
Yes
History of herpes infection at the procedure site*
No
Yes
History of heart valve disease*
No
Yes
Do you have any allergies?*
No
Yes
Skin conditions*
No
Yes
Do you use any medications that might affect the healing of the tattoo you wish to receive*
No
Yes
Is there any information that you feel you should provide to the body art practitioner*
No
Yes
Important Health & Allergy Information Please disclose any allergies, medical conditions, sensitivities, medications, or other health concerns that may affect your tattoo procedure. While this waiver collects important health information, it is your responsibility to discuss any allergies, concerns, or special considerations directly with your tattoo artist before the procedure begins. This includes any information you believe may impact your safety, comfort, healing process, or the outcome of your tattoo. If you are unsure whether a condition, medication, or allergy is relevant, please inform your artist prior to your appointment. *
I understand it's my responsibility to speak with my artist.
Who will be doing your tattoo today?
Location on body *
Tattoo Design *
How did you hear about us *
Referral
Social media
Google
Other
Third Client's Name
First Name*
Middle Name
Last Name*
Phone*
Client's Date of Birth*
Date of Birth
Information
Allergic reactions to latex*
No
Yes
Diabetes*
No
Yes
Hemophilia or bleeding disorder*
No
Yes
Scarring/keloiding*
No
Yes
Any risk for blood borne pathogens*
No
Yes
Allergic reactions to antibiotics*
No
Yes
History of herpes infection at the procedure site*
No
Yes
History of heart valve disease*
No
Yes
Do you have any allergies?*
No
Yes
Skin conditions*
No
Yes
Do you use any medications that might affect the healing of the tattoo you wish to receive*
No
Yes
Is there any information that you feel you should provide to the body art practitioner*
No
Yes
Important Health & Allergy Information Please disclose any allergies, medical conditions, sensitivities, medications, or other health concerns that may affect your tattoo procedure. While this waiver collects important health information, it is your responsibility to discuss any allergies, concerns, or special considerations directly with your tattoo artist before the procedure begins. This includes any information you believe may impact your safety, comfort, healing process, or the outcome of your tattoo. If you are unsure whether a condition, medication, or allergy is relevant, please inform your artist prior to your appointment. *
I understand it's my responsibility to speak with my artist.
Who will be doing your tattoo today?
Location on body *
Tattoo Design *
How did you hear about us *
Referral
Social media
Google
Other
Fourth Client's Name
First Name*
Middle Name
Last Name*
Phone*
Client's Date of Birth*
Date of Birth
Information
Allergic reactions to latex*
No
Yes
Diabetes*
No
Yes
Hemophilia or bleeding disorder*
No
Yes
Scarring/keloiding*
No
Yes
Any risk for blood borne pathogens*
No
Yes
Allergic reactions to antibiotics*
No
Yes
History of herpes infection at the procedure site*
No
Yes
History of heart valve disease*
No
Yes
Do you have any allergies?*
No
Yes
Skin conditions*
No
Yes
Do you use any medications that might affect the healing of the tattoo you wish to receive*
No
Yes
Is there any information that you feel you should provide to the body art practitioner*
No
Yes
Important Health & Allergy Information Please disclose any allergies, medical conditions, sensitivities, medications, or other health concerns that may affect your tattoo procedure. While this waiver collects important health information, it is your responsibility to discuss any allergies, concerns, or special considerations directly with your tattoo artist before the procedure begins. This includes any information you believe may impact your safety, comfort, healing process, or the outcome of your tattoo. If you are unsure whether a condition, medication, or allergy is relevant, please inform your artist prior to your appointment. *
I understand it's my responsibility to speak with my artist.
Who will be doing your tattoo today?
Location on body *
Tattoo Design *
How did you hear about us *
Referral
Social media
Google
Other
Fifth Client's Name
First Name*
Middle Name
Last Name*
Phone*
Client's Date of Birth*
Date of Birth
Information
Allergic reactions to latex*
No
Yes
Diabetes*
No
Yes
Hemophilia or bleeding disorder*
No
Yes
Scarring/keloiding*
No
Yes
Any risk for blood borne pathogens*
No
Yes
Allergic reactions to antibiotics*
No
Yes
History of herpes infection at the procedure site*
No
Yes
History of heart valve disease*
No
Yes
Do you have any allergies?*
No
Yes
Skin conditions*
No
Yes
Do you use any medications that might affect the healing of the tattoo you wish to receive*
No
Yes
Is there any information that you feel you should provide to the body art practitioner*
No
Yes
Important Health & Allergy Information Please disclose any allergies, medical conditions, sensitivities, medications, or other health concerns that may affect your tattoo procedure. While this waiver collects important health information, it is your responsibility to discuss any allergies, concerns, or special considerations directly with your tattoo artist before the procedure begins. This includes any information you believe may impact your safety, comfort, healing process, or the outcome of your tattoo. If you are unsure whether a condition, medication, or allergy is relevant, please inform your artist prior to your appointment. *
I understand it's my responsibility to speak with my artist.
Who will be doing your tattoo today?
Location on body *
Tattoo Design *
How did you hear about us *
Referral
Social media
Google
Other
Sixth Client's Name
First Name*
Middle Name
Last Name*
Phone*
Client's Date of Birth*
Date of Birth
Information
Allergic reactions to latex*
No
Yes
Diabetes*
No
Yes
Hemophilia or bleeding disorder*
No
Yes
Scarring/keloiding*
No
Yes
Any risk for blood borne pathogens*
No
Yes
Allergic reactions to antibiotics*
No
Yes
History of herpes infection at the procedure site*
No
Yes
History of heart valve disease*
No
Yes
Do you have any allergies?*
No
Yes
Skin conditions*
No
Yes
Do you use any medications that might affect the healing of the tattoo you wish to receive*
No
Yes
Is there any information that you feel you should provide to the body art practitioner*
No
Yes
Important Health & Allergy Information Please disclose any allergies, medical conditions, sensitivities, medications, or other health concerns that may affect your tattoo procedure. While this waiver collects important health information, it is your responsibility to discuss any allergies, concerns, or special considerations directly with your tattoo artist before the procedure begins. This includes any information you believe may impact your safety, comfort, healing process, or the outcome of your tattoo. If you are unsure whether a condition, medication, or allergy is relevant, please inform your artist prior to your appointment. *
I understand it's my responsibility to speak with my artist.
Who will be doing your tattoo today?
Location on body *
Tattoo Design *
How did you hear about us *
Referral
Social media
Google
Other
Seventh Client's Name
First Name*
Middle Name
Last Name*
Phone*
Client's Date of Birth*
Date of Birth
Information
Allergic reactions to latex*
No
Yes
Diabetes*
No
Yes
Hemophilia or bleeding disorder*
No
Yes
Scarring/keloiding*
No
Yes
Any risk for blood borne pathogens*
No
Yes
Allergic reactions to antibiotics*
No
Yes
History of herpes infection at the procedure site*
No
Yes
History of heart valve disease*
No
Yes
Do you have any allergies?*
No
Yes
Skin conditions*
No
Yes
Do you use any medications that might affect the healing of the tattoo you wish to receive*
No
Yes
Is there any information that you feel you should provide to the body art practitioner*
No
Yes
Important Health & Allergy Information Please disclose any allergies, medical conditions, sensitivities, medications, or other health concerns that may affect your tattoo procedure. While this waiver collects important health information, it is your responsibility to discuss any allergies, concerns, or special considerations directly with your tattoo artist before the procedure begins. This includes any information you believe may impact your safety, comfort, healing process, or the outcome of your tattoo. If you are unsure whether a condition, medication, or allergy is relevant, please inform your artist prior to your appointment. *
I understand it's my responsibility to speak with my artist.
Who will be doing your tattoo today?
Location on body *
Tattoo Design *
How did you hear about us *
Referral
Social media
Google
Other
Eighth Client's Name
First Name*
Middle Name
Last Name*
Phone*
Client's Date of Birth*
Date of Birth
Information
Allergic reactions to latex*
No
Yes
Diabetes*
No
Yes
Hemophilia or bleeding disorder*
No
Yes
Scarring/keloiding*
No
Yes
Any risk for blood borne pathogens*
No
Yes
Allergic reactions to antibiotics*
No
Yes
History of herpes infection at the procedure site*
No
Yes
History of heart valve disease*
No
Yes
Do you have any allergies?*
No
Yes
Skin conditions*
No
Yes
Do you use any medications that might affect the healing of the tattoo you wish to receive*
No
Yes
Is there any information that you feel you should provide to the body art practitioner*
No
Yes
Important Health & Allergy Information Please disclose any allergies, medical conditions, sensitivities, medications, or other health concerns that may affect your tattoo procedure. While this waiver collects important health information, it is your responsibility to discuss any allergies, concerns, or special considerations directly with your tattoo artist before the procedure begins. This includes any information you believe may impact your safety, comfort, healing process, or the outcome of your tattoo. If you are unsure whether a condition, medication, or allergy is relevant, please inform your artist prior to your appointment. *
I understand it's my responsibility to speak with my artist.
Who will be doing your tattoo today?
Location on body *
Tattoo Design *
How did you hear about us *
Referral
Social media
Google
Other
Ninth Client's Name
First Name*
Middle Name
Last Name*
Phone*
Client's Date of Birth*
Date of Birth
Information
Allergic reactions to latex*
No
Yes
Diabetes*
No
Yes
Hemophilia or bleeding disorder*
No
Yes
Scarring/keloiding*
No
Yes
Any risk for blood borne pathogens*
No
Yes
Allergic reactions to antibiotics*
No
Yes
History of herpes infection at the procedure site*
No
Yes
History of heart valve disease*
No
Yes
Do you have any allergies?*
No
Yes
Skin conditions*
No
Yes
Do you use any medications that might affect the healing of the tattoo you wish to receive*
No
Yes
Is there any information that you feel you should provide to the body art practitioner*
No
Yes
Important Health & Allergy Information Please disclose any allergies, medical conditions, sensitivities, medications, or other health concerns that may affect your tattoo procedure. While this waiver collects important health information, it is your responsibility to discuss any allergies, concerns, or special considerations directly with your tattoo artist before the procedure begins. This includes any information you believe may impact your safety, comfort, healing process, or the outcome of your tattoo. If you are unsure whether a condition, medication, or allergy is relevant, please inform your artist prior to your appointment. *
I understand it's my responsibility to speak with my artist.
Who will be doing your tattoo today?
Location on body *
Tattoo Design *
How did you hear about us *
Referral
Social media
Google
Other
Tenth Client's Name
First Name*
Middle Name
Last Name*
Phone*
Client's Date of Birth*
Date of Birth
Information
Allergic reactions to latex*
No
Yes
Diabetes*
No
Yes
Hemophilia or bleeding disorder*
No
Yes
Scarring/keloiding*
No
Yes
Any risk for blood borne pathogens*
No
Yes
Allergic reactions to antibiotics*
No
Yes
History of herpes infection at the procedure site*
No
Yes
History of heart valve disease*
No
Yes
Do you have any allergies?*
No
Yes
Skin conditions*
No
Yes
Do you use any medications that might affect the healing of the tattoo you wish to receive*
No
Yes
Is there any information that you feel you should provide to the body art practitioner*
No
Yes
Important Health & Allergy Information Please disclose any allergies, medical conditions, sensitivities, medications, or other health concerns that may affect your tattoo procedure. While this waiver collects important health information, it is your responsibility to discuss any allergies, concerns, or special considerations directly with your tattoo artist before the procedure begins. This includes any information you believe may impact your safety, comfort, healing process, or the outcome of your tattoo. If you are unsure whether a condition, medication, or allergy is relevant, please inform your artist prior to your appointment. *
I understand it's my responsibility to speak with my artist.
Who will be doing your tattoo today?
Location on body *
Tattoo Design *
How did you hear about us *
Referral
Social media
Google
Other
Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address
Email
Check to receive information, news, and discounts by e-mail & text message.
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Parent or Guardian's Driver's License / ID Card
Driver's License / ID Card Number*
Issuing State*
For Your Artist To Fill Out: Ink Model, Lot Number, and Expiration DO NOT ENTER INFORMATION Unless you are the Artist.
Inks used for your procedure. *
Model: Dynamic Black Ink Lot # 72022121 EXP. / 12/12/27
Model: Dynamic White Ink Lot # 82020211 EXP. / 11/20/28
Model: Eternal Ink (Red) Lot # P010925 EXP. /290110
Model: Eternal Ink (Blue) Lot #N091924 EXP. / 281001
Model: Eternal Ink (Green) Lot # N041824 EXP. / 280430
Model: Eternal Ink (Yellow) 250516 Lot # 290516 EXP. /
Model: Eternal Ink (Purple) Lot # P051525 EXP. / 290508
Model: Eternal Ink (Orange) Lot # P021325 EXP. / 290204
Model: Eternal Ink (Brown) Lot # P050125 EXP. / 290425
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Information
Allergic reactions to latex*
No
Yes
Diabetes*
No
Yes
Hemophilia or bleeding disorder*
No
Yes
Scarring/keloiding*
No
Yes
Any risk for blood borne pathogens*
No
Yes
Allergic reactions to antibiotics*
No
Yes
History of herpes infection at the procedure site*
No
Yes
History of heart valve disease*
No
Yes
Do you have any allergies?*
No
Yes
Skin conditions*
No
Yes
Do you use any medications that might affect the healing of the tattoo you wish to receive*
No
Yes
Is there any information that you feel you should provide to the body art practitioner*
No
Yes
Important Health & Allergy Information Please disclose any allergies, medical conditions, sensitivities, medications, or other health concerns that may affect your tattoo procedure. While this waiver collects important health information, it is your responsibility to discuss any allergies, concerns, or special considerations directly with your tattoo artist before the procedure begins. This includes any information you believe may impact your safety, comfort, healing process, or the outcome of your tattoo. If you are unsure whether a condition, medication, or allergy is relevant, please inform your artist prior to your appointment. *
I understand it's my responsibility to speak with my artist.
Who will be doing your tattoo today?
Location on body *
Tattoo Design *
How did you hear about us *
Referral
Social media
Google
Other
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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