This field is for validation purposes and should be left unchanged.

Medical History, Consent and Release for Tattoo
(Customer must fill form out in its entirety and provide copy of ID)

Date(Required)

Customer Name(Required)

First Last

Date of Birth(Required)

Age(Required)

Please enter a number from 13 to 100.

Phone(Required)

Email(Required)

Customer Address(Required)

Street Address Address Line 2 City State ZIP Code

Race(Required)

African American

American Indian

Asian

Hispanic/Latino

White

Other

Photo of Drivers License (ID)(Required)

Please take a photo of the front of your ID.

Max. file size: 12 GB.

Emergency Contact Name(Required)

Emergency Contact Number(Required)

Do you know your doctors name/phone number/address?(Required)

Yes

Physician or Clinic Name(Required)

Lakeland Regional Hospital

Physician or Clinic Number(Required)

Physician or Clinic Address(Required)

Street Address Address Line 2 City State ZIP Code

Physician or Clinic Address(Required)

Street Address Address Line 2 City State ZIP Code