Consent Form

Name *

First Name

Last Name

Phone *

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I have been fully informed of the inherent risks associated with getting a tattoo or piercing. I fully understand that these risks, known and unknown, can lead to injury, including but not limited to infection, scarring, difficulties in detecting melanoma and allergic reactions to tattoo pigment, latex gloves, and/or soap. Having been informed of the potential risks associated with getting a tattoo or piercing, I still wish to proceed with the tattoo application or piercing and I freely accept and expressly assume any and all risks that may arise from this action.

I waive and release to the fullest extent permitted by the law each pf the practitioners and the facility from all liability whatsoever, for any and all claims of causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise from the application of my tattoo, whether caused by the negligence or fault of either the practitioner, facility, or otherwise.

That the practitioner or the facility representative have given me the full opportunity to ask any and all questions about the application of my tattoo or piercing procedure and all of my questions have been answered to my complete satisfaction.

The practitioner of the facility representative have given me instructions on the care of my tattoo or piercing while it's healing and understand and will follow them. I acknowledge that it is possible that the tattoo or piercing may become infected, particularly if I do not follow the instructions given to me. I agree that it is my responsibility to contact the practitioner or facility if there are signs or symptoms of infection including but not limited to swelling, tenderness of the procedure area, red streaks going from the procedure area towards the heart, elevated body temperature, or purulent drainage from the procedure area. If any touch-up work to the tattoo or piercing is needed due to my own negligence, I agree that the work will be done at my own expense.

I am not under the influence of alcohol or drugs, and I am voluntarily submitting to be tattooed or pierced by the practitioner without duress or coercion.

I do not have diabetes, epilepsy, hemophilia, herpes, a heart condition, nor do I take blood thinning medication. I do not have any other medical or skin condition that may interfere with the application or healing of the tattoo or piercing. I am not the recipient of an organ or bone marrow transplant or, if I am, I have taken the prescribed preventive regimen of antibiotics that is required by my doctor in advance of any invasive procedure such as tattooing or piercing. I am not pregnant or nursing. I do not have metal impairment that may affect my judgment in getting a tattoo or piercing. I do not have allergic reactions to latex gloves.

Neither the practitioner, nor the facility is responsible for the meaning or spelling or the symbol or text that I have provided to them, chosen from the flash (design) sheets or drawn/designed by the practitioner by my direction.

Variations in color and design may exist between the tattoo art I have selected and the actual tattoo when it is applied to my body. I also understand that over time, the colors and clarity of my tattoo will fade due to unprotected exposure to the sun and the naturally occurring dispersion of pigment under the skin.

A tattoo is a permanent change to my appearance and can only be removed by laser or surgical means, which can be disfigured and/or costly and which in all likelihood will not result in the restoration of my skin to its exact appearance before being tattooed.

I release all rights to any photographs taken of me and the tattoo and give consent in advance to their reproduction in print of electronic form. (If you do not initial this provision, please advise and remind your practitioner and the facility NOT to take any pictures of you or your completed tattoo!)

I agree to reimburse each of the practitioner and the facility for any/all attorney's fees and costs incurred in any legal action I bring against either the practitioner or the facility and in which either the practitioner or the facility is the prevailing party. I agree that the courts shall have personal jurisdiction and venue over me and shall have exclusive jurisdiction for the purpose of litigating any dispute arising out of or related to this agreement.

I acknowledge that I have been given adequate opportunity to read and understand this document prior to receiving my procedure and that is was not presented to me at the last minute. I understand that I am signing a legal contract waiving certain rights to recover damages against the practitioner and the above said facility.