717 Tattoo & Body Piercing Procedure Waiver

Your Full Name*

First NameLast Name

Email

example@example.com

Phone Number*

Area CodePhone Number

This agreement is made between 717 Tattoo, its affiliates, consultants, business associates, contractors, workers, owners, assets and like, hereafter referred to as "717 Tattoo" and "THE CLIENT" or "I" as undersigned, including heirs, next of kin, etc, in regards to the procedure indicted on this form, hereafter referred to as the "procedure".

The date of my appointment is

Date

My procedure will be completed at the following 717 Tattoo location:*

717 Tattoo - Highspire717 Tattoo - Columbia717 Tattoo - Mechanicsburg717 Tattoo - Harrisburg

I understand that this is a binding contract with 717 Tattoo & I have been given full opportunity to ask any and all questions about my procedure. All of my questions have been answered to my satisfaction. I understand that my procedure may be permanent, and may require surgical procedure for removal. I am aware that removal may cause scarring.*

I agree to this statement

I do not have any medical conditions or communicable diseases (including but not limited to diabetes, epilepsy, hemophilia, hepatitis, HIV, AIDS, tuberculosis, COVID19). I do not have a skin condition that may interfere with the proper healing of my procedure (including but not limited to acne, scarring or keloids, eczema, psoriasis, freckles, moles, or sunburn). I am not pregnant or nursing. I have informed the agent of 717 Tattoo and documented below of any exceptions to the above. I do not have a mental, physical, or medical condition which may a) have an adverse effect on my procedure, or b) effect my ability to make a decision about having my procedure completed. I am not under the influence of drugs, alcohol, or any narcotic, including but not limited to prescription pharmaceuticals, & over the counter medications. I am aware that being under the influence can have an adverse effect on the procedure. I agree that 717 Tattoo cannot determine if I will have an allergic reaction to any of the products used to complete my procedure. I attest that I have no known allergies, or if I do I have documented them on the back of this form and alerted the agent of 717 Tattoo.*

I agree to this statement

I am aware of the possibility of infection with my procedure. I understand that when I leave the premises of 717 Tattoo, my procedure is only half complete. It is my responsibility to follow the aftercare procedures recommended by 717 Tattoo. 717 Tattoo makes no claim to the success or validity of the recommended aftercare procedures, they are simply guidelines. I agree to not hold 717 Tattoo liable for any necessary touch-up work cause by my own negligence. I understand that skin color will have an effect on the final result of my tattoo. I agree to leave the premises of 717 Tattoo or any other location where 717 Tattoo is engaged in business promptly upon request, for any reason whatsoever, by any employee or agent of 717 Tattoo.*

I agree to this statement

If my procedure involves the application of a symbol, 717 Tattoo is not responsible for what the symbol may or may not mean. If my procedure involves the application of a word or a date, I have shown the spelling to the agent of 717 Tattoo. If I fail to do so, 717 Tattoo is not responsible for a misspelling. I was furnished a copy of this document via email.*

I agree to this statement

I have uploaded legal identification below & attest that I am 18 years of age, or older. If I am under the age of 18, I have a legal guardian present who has also furnished legal identification, and signed below. I attest that the information and identification is true and correct. I consent to the procedure. I release and waive all rights to any of the photographs and/or video taken of my procedure or during my procedure. I consent to the use of this media in print and/or electronic form, exhibition in any venue, advertisement, or in any other way 717 Tattoo would see fit.*

I agree to this statement

Please upload a photo of valid identification. Identification can include State issued driver's license or Photo ID, military ID, US passport, Social Security card, etc. The ID must be current. If the ID does not include a photo, please upload a second document in the next field.*

Browse Files

Please allow your upload to finish before submitting. Please take a clear & readable picture of your identification

If your identification above does not include a photo, please upload a photo ID below, such as a school ID, work ID, etc

Browse Files

Please allow your upload to finish before submitting. Please take a clear & readable picture of your identification

I agree that the inability to legally enforce any one part of this agreement will have no bearing on the legality or enforce-ability of the remainder of the agreement. Being of sound mind & body, I agree to hold 717 Tattoo free from any & all claims, damages, demands, rights, legal actions, cause of actions, claim judgments, costs of litigation, attorneys fees, or any cost which may result from and/or as a result of my procedure. I agree that this contract is a waiver pertaining to all locations where 717 Tattoo is conducting business, & applies to any heirs or executors of estate. I agree to pay any & all damages to any & all persons & property belonging to 717 Tattoo or any other person who may become liable contractually where by operation of law, caused by, or resulting from my decision to have this procedure performed.*

I agree to this statement

Please use this section identify any exceptions or concerns you may have regarding this agreement.

Today's Date*

Date

Signature*