Client Information
Full Name
*
First Name
Last Name
Preferred Name
First Name
Last Name
Pronouns
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Artist
*
Payne
Haji
Shauntell
Michele
Ezio
Sarah G.
Kimber
Tall Dave
Mollie
Melon
Gemini
Justin
Jimi
Danielle (Apprentice)
Emily (Apprentice)
Guest Artist
I hereby give consent to Zen Ink, LLC to perform a tattoo and in consideration of doing so, I hereby release and forever discharge and hold harmless Zen Ink, LLC, the Tattooist and all affiliates, Owners, Managers and Independent Contractors from any and all claims, damages or legal actions arising from or connected in any way with my tattoo, or the procedure and conduct used in my performing my tattoo, to the fullest extent allowed by the law.
*
Yes
No
I fully understand that any Independent contractor of Zen Ink, LLC when performing a tattoo, does not act in the capacity as a medical professional. The suggestions made by any Independent Contractor or agent of Zen Ink, LLC are just suggestions. They are not to be construed as, or substituted for advice from a medical professional. I understand that the tattoo will be performed using appropriate techniques, instruments, and pigments.
*
Yes
No
To ensure proper healing of my tattoo, I agree to follow the written and verbal aftercare instructions that will be provided, until healing is complete. I understand that infections can occur due to lack of proper hygiene and/or pigment sensitivities. I agree that any touch up work, due to my negligence, will be done at my own expense. I understand that a tattoo may take 4-8 weeks to heal properly.
*
Yes
No
For tattoos in the areas of: Fingers, Hands, Inner Lip, Side of Foot, Bend of wrist, I understand that getting a tattoo in any of the above areas is not guaranteed to stay. It will likely fade or disappear. Touch ups (in any of the listed areas) are to be done at the expense of the client. Likely at the rate of the shop minimum each time.
*
Yes
No
I understand that I am making a permanent change to my body, and no claims about the possibility of reversing these changes have been made or implied by Zen Ink, LLC or any of its Independent Contractors or agents.
*
Yes
No
I agree that these waivers also pertain to and are designed to protect any and all establishments of Zen Ink and their Independent Contractors.
*
Yes
No
I am at least 18 years old.
*
Yes
No
Do you have a heart condition?
*
Yes
No
Other
Do you have Diabetes?
*
Yes
No
Other
Do you have Epilepsy?
*
Yes
No
Other
Do you suffer from Hemophilia?
*
Yes
No
Other
Do you have any communicable diseases (ex: hiv, hepatitis)?
*
Yes
No
Other
Do you have sunburn, discoloration, lumps around the tattoo area?
*
Yes
No
Other
Are you pregnant/breastfeeding?
*
Yes
No
Other
Have you eaten in the last 5 hours? It's a good idea to eat before hand to increase your blood sugar levels. (If you have not, there is a higher risk for passing out/getting sick, so please ASK us for a snack before we start).
*
Yes
No
Other
Do you suffer from any condition that makes this procedure dangerous?
*
Yes
No
Other
Have you consumed drugs/alcohol in the last 8 hours? if so, what and how many?
*
Yes
No
Other
Have you recently taken: blood thinners, antibiotics, prednisone, accutane?
*
Yes
No
Other
Are you prone to fainting?
*
Yes
No
Other
Client is responsible for checking for spelling and correct dates. I agree to check spelling and dates with my artist before the tattoo. I agree to placement of the stencil prior to tattooing.
*
Yes
No
I agree to speak softly and silence my cell phone in order to help keep a calm, spa like environment.
*
Yes
No
If being tattooed by an apprentice, I acknowledge and I am fully aware that my tattoo artist is an apprentice and still learning. I understand that apprenticeships are a form of on-the-job training where the art of the tattoo can be taught, along with techniques for avoiding blood-borne pathogens, handling needles, and studio etiquette. I understand that apprentices are still getting valuable hands-on experience and learning the craft of tattooing. I am aware that this tattoo apprentice does have valid up to date Blood Borne Pathogen (BBP) training certificate and is registered as a Body Art Practitioner with the county Health Department. I understand the risks involved and consent to be tattooed by this tattoo apprentice.
Yes
No
Not Applicable
Are you currently sick? In the last 14 days, have you been sick or been in contact with anyone that is sick.
*
Yes
No
I understand that getting tattooed does temporarily stress the body and the immune system, which could make me more susceptible to illness and infection. I accept this risk.
*
Yes
No
I understand the Zen Ink has put additional protective measures in place in order to reduce the risk of contamination, virus, or pathogen but it is impossible to completely eliminate that risk.
*
Yes
No
I agree to release and forever hold harmless Zen Ink and its agents and representatives for any and all claims, damages, or legal actions in the event I contract COVID-19 or any other illness after choosing to get tattooed.
*
Yes
No
I agree that Zen Ink has a zero tolerance policy regarding professional boundaries. This includes harassment of an artist verbally or physically. I agree to behave respectfully and maintain professional boundaries at all times.
*
Yes
No
I understand that if I am getting a coverup tattoo that it is possible that portions of the old tattoo may show through. I understand that coverups may take multiple sessions to complete. I also understand that a coverup tattoo cannot cover existing scarring/scar tissue. Furthermore, I understand that with time and sun exposure the old tattoo may show through more than it did initially. Any touch ups on coverup tattoos, to layer in more ink, are at the customers expense.
*
Yes
No
I consent to Authorization for Picture of my Tattoo to be used on Social Media, Website etc. (This will only be a close up of the tattooed area.)
*
Yes
No
Some of the products we use may contain the ingredients below. Are you allergic to any of the following?
*
Latex
Adhesives
Lavender, Tea Tree, Peppermint Oils
Sunflower, Cotton Seed, Chamomile, Jojoba, Coconut Oils
Shea, Mango, Cocoa and Aloe Butters
Beeswax
Witch Hazel
Lidocaine
Rosemary Oil
Green Tea
Vitamin E
Papaya
Clove
NONE
Other
Please list any medications you take
How did you hear about us?
*
Repeat Client
Referral
Instagram
Radio
Dig Local Website/App
Go Local Discount Card
Silverados
Best of WNC
TikTok
Other
Acknowledgment and Waiver
*
I have read this release form and confirm that all the information I have given is correct. I understand that this is a release form and I agree to be legally bound by it.
*
I understand there are no refunds.
*
I understand that I need to take care of the tattoo by following the instructions given to me by the Tattoo Shop.
*
I confirm that the information I provided in this document is accurate and true.
Signed Date
*
-
Month
-
Day
Year
Date
Client Signature
*
Please take a picture of your ID or passport
*
Submit
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