TATTOO RELEASE FORM

NAME*

DATE OF BIRTH*

Date

ADDRESS*

CITY*

STATE*

ZIP CODE*

PHONE*

EMAIL*

example@example.com

EMERGENCY CONTACT*

I understand that I am responsible for the correct spelling, grammar, punctuation, language and any dates or text of my tattoo .*

Yes

1. Are you allergic to Latex?*

YesNo

2. Are you pregnant?*

YesNo

3. Are you currently under the influence of drugs or alcohol?*

YesNo

4. Do you have diabetes, epilepsy, hemophilia, a heart condition, or take blood thinning medication?*

YesNo

5. Do you have any kind of communicable diseases such as Hepatitis, HIV, or AIDS?*

YesNo

Pick your Artist*

Select your location.

Please choose one Walk In | Returning Client*

Upload Drivers License*

Price Set by Artist*

Describe your Tattoo or Piercing*

Initials*

I fully understand that these risks, known and unknown, can lead to serious injury, including but not limited to, infection, scarring, difficulties in detecting melanoma and allergic reactions to tattoo pigment, latex gloves, and/or soap. I freely accept and expressly assume any and all risks that may arise from being tattooed. I agree to waive and release, to the fullest extent permitted. By law, Umbrella Art Collective Tattoos & Piercing and all artists associated with Umbrella Art Collective Tattoos & Piercing from all liability whatsoever, for any and all claims or 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 artist or Umbrella Art Collective Tattoos & Piercing, or otherwise. I agree that I am solely responsible, if I do not follow proper after care instructions or if I use any product that is not recommended by the artist or Umbrella Art Collective Tattoos & Piercing. I agree to reimburse each of the artist and Umbrella Art Collective Tattoos & Piercing for any attorney’s fees and costs incurred in any legal action I bring against either the artist or Umbrella Art Collective Tattoos & Piercing and in which either the artist or Umbrella Art Collective Tattoos & Piercing is the prevailing party. I agree that the courts of Georgia in Richmond 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 this agreement. I, am at least 18 years of age or, older with proper identification and give full consent willfully or use over any photos taken and body parts that may be expose, touched, accidentally rubbed during the tattoo or piercing.*

I UNDERSTAND AND CONSENT

I waive all rights for all photos taken and give permission to be used for marketing purposes on any platform print, or online.*

I UNDERSTAND AND CONSENT

Signature Date*

Date

Complaints or Concerns: Richmond County Enviromental Health at 706-667-4234