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Waiver, Release, and Consent Contract
Please read carefully and be sure that you understand the implications of signing.
Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Phone Number
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Area Code
Phone Number
Email
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example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please take a picture of the front of your drivers license, if you can't please email a picture of it the shop and/or bring your drivers license with you to your appointment
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Pre-Procedure Questionnaire
FEMALE ONLY: Pregnancy or Nursing?
Yes
No
Do you have a communicable disease?
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Yes
No
Skin conditions (e.g. Rashes, eczema, infection, psoriasis, freckles, etc.)
If yes, please identify the condition.
Medical History (e.g. DIabetes, Cardiovascular Disease, Epilepsy, Blood-related disease etc.)
If yes, please identify the condition.
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*
I am not under the influence of alcohol or drugs, and I am voluntarily submitting to be tattooed by the tattoo artist without duress or coercion.
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I have been informed of the inherent risks associated with receiving a tattoo. 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. I also understand that the FDA has not approved tattoo inks, dyes and pigments, and that the health consequences of using these products are unknown. Having been informed of the potential risks associated with getting a tattoo, I still wish to undergo the tattoo application and freely and expressly assume any and all risks that may arise from tattooing.
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I WAIVE AND RELEASE, to the fullest extent permitted by law, each of the tattoo artists and Petaluma Tattoo as a whole from all liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors, assigns, or agents may have for personal injury or otherwise; including any direct and/or indirect consequential damages, which result or arise from the application of my tattoo-whether cause by the negligence or fault of either the tattoo artist or Petaluma Tattoo as a whole or otherwise.
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Both the tattoo artist and Petaluma Tattoo as a whole have given me the full opportunity to ask any and all questions about the application of my tattoo and all my questions have been answered to my total satisfaction.
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Both the tattoo artist and Petaluma Tattoo as a whole have given me instructions on the care of my tattoo during its healing process, and I both understand and agree to follow them. I acknowledge and understand that it is possible that my tattoo can become infected as a result of my own actions, particularly if I neglect to follow the care instructions offered and provided (including gardening or coming in close contact with animals). I am aware of the signs and symptoms of any infection, superficial or otherwise, that they can include but are not limited to: redness, swelling, tenderness (each regarding the procedure site), red streaks from the procedure site towards the heart, elevated temperature, or purulent drainage from the procedure site.
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I do not have epilepsy, hemophilia, cardiac valve disease, a history of herpes infection at the proposed procedure site, 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 or the tattoo such as an allergy to latex or antibiotics. I am not the recipient of an organ or tissue transplant, or if I am, I have taken the prescribed regimen or antibiotics or medication that is required by my doctor or medical professional in advance of any invasive procedure such as tattooing. I do not have a mental impairment that may affect my judgement about getting a tattoo.
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If I have diabetes, I confirm that my blood sugar and diabetes is under control. If my diabetes is not well controlled, I will take measures to get my diabetes within range prior to getting a tattoo. You may also check this box, if you do not have diabetes.
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I acknowledge that Petaluma Tattoo has put in place preventative measures to reduce the spread of Covid-19 yet cannot guarantee that I will not become infected with Covid-19.
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I attest that I am not experiencing any symptom of illness such as cough, shortness of breath, difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell. I further attest that I have not been diagnosed with Covid-19 and if I have, I have been cleared as non-contagious by state or local health authorities.
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I hereby release and agree to hold Petaluma Tattoo harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the salon, or that may otherwise arise in any way in connection with any services received from Petaluma Tattoo. I understand that this release discharges Petaluma Tattoo from any liability or claim that I, my heirs, or any personal representatives may have against the salon with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Petaluma Tattoo. This liability waiver and release extends to the tattoo shop together with all owners, partners, and employees.
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If I develop any form of infection in the procedure area I will contact Petaluma Tattoo as well as go see my doctor.
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Variations in color and design may exist between the tattoo art I have selected and the actual tattoo when applied to the body. I also understand that over time the colors and the clarity of my tattoo will fade due to unprotected exposure to the sun and the naturally occurring dispersion of pigment under my skin.
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Both the tattoo artist and Petaluma Tattoo as a whole are NOT responsible for the meaning or spelling of the symbol or text that I have provided to them or chosen from my desired source.
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Touch-ups, if needed, are given within no longer than one year after the completion of the tattoo at the artist’s discretion, a $20 sterile set-up charge may apply. Should any touch-up work to the tattoo be needed due to my own negligence, I agree that the work will be done at a cost to me at a rate agreed upon with the artist.
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I agree to reimburse each of the tattoo artist and the tattoo studio, Petaluma Tattoo as a whole, for any attorney’s fees and cost incurred in any legal action I bring against either the tattoo artist or Petaluma Tattoo as a whole, as the prevailing party. I agree the courts of California in Sonoma County 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 the agreement.
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I acknowledge that tattooing is a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove my tattoo.
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I understand that any and all cash tendered is non-refundable. All cancellations and rescheduling must be done at least 24 hours prior to the appointment date and time. No-shows without prior notice will result in loss of any and all deposits.
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I release all right to any photographs taken or me and/or the tattoo. I give consent in advance to their reproduction in print or electronic form (I understand that if I do not initial and agree to this it is my responsibility to inform the tattoo artist of such).
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I will be 18 years or older at the time of my appointment
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I have chosen, agreed upon, and informed my artist of my desired location of my tattoo
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I acknowledge that I have been given adequate opportunity to read and understand this document, that it was not presented to me at the last minute, and I understand that I’m signing a legal contract waiving certain rights to recover against the tattoo artist and Petaluma Tattoo as a whole.
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I confirm that the information I provided in this document is accurate and true and declare that I I am in a competent state to sign this agreement.
Signed Date
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Month
-
Day
Year
Date
Client Signature
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Submit
Should be Empty: