REGISTRATION FORM - CUSTOMER | kliniktattooshop.be

Name and last name *
 E-mail *
 Phone number *
 Age + parent's approval (only to be completed if you are a minor / minimum 17 years young)
 Write here the name of your artist + date of appointment *
 I am in good health *YES
NO
 I have hemophilia, bleeding, or bruising. *YES
NO
 I have heart problems or epilepsy. *YES
NO
 I have high or low blood pressure. *YES
NO
 I have STDs or HIV. *YES
NO
 I have Hepatitis A, B or C. *YES
NO
 I am allergic. *YES
NO
 I use blood thinners. *YES
NO
 I am pregnant and / or breastfeeding. *YES
NO
 I quickly get dizzy, nauseous or faint. *YES
NO
 How did I end up at Studio Klinik? *Referred by friends
By passage.
Via internet - social media.
Others.
 Can we keep this data for our customer base?YES
NO
 Would you like to receive a copy of this registration form (only by email)?YES
NO
 some-randome-random
 
Belgian Royal Decree