Client’s Confirmation of High Blood Pressure

I (client’s name)____________________________________ acknowledge that I am regularly visiting my doctor regarding my high blood pressure and this is controlled by medication.

I do not have any of the following medical health conditions relating to high blood pressure.

	Yes	No
Stroke
Structural heart problems
Diabetes
Angina or previous Myocardial Infarction (Heart Attack)
Chronic kidney disease
Ischemic heart disease (IHD) or Myocardial Ischaemia

Client’s Name: _________________________________________________

Client’s Signature: _________________________________________________

Date: ___ / ___ / ______

---

Doctor’s Consent Form

For the attention of Doctor ________________________________________

Your patient ___________________________________ has contacted me hoping to receiving a permanent cosmetic tattoo. The process involves implanting pigment into the dermal layer of the skin, where it remains for a number of years.

As your patient has indicated a medical condition during my pre-procedure consultation with them, I ask that you consider the possible implications of the procedure and give your consent to them receiving the procedure.

If you feel that the procedure would have no detrimental effect to the health of your patient, please complete the details below.

Doctor’s Name: _________________________________________________

Surgery Name: _________________________________________________

Surgery Address: ________________________________________________________________________

________________________________________________________________________________________

I understand that (patient’s name) __________________________________ is to receive a permanent cosmetic tattoo. I have considered my patient’s medical condition and feel that this procedure will have no detrimental effect on their health.

Signed: __________________________________________ Date: ___ / ___ / ______