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27
Preguntas
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1
Today's Date
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Date
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2
Are you 18 years of age or older?
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3
What brings you in?
Appointment
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4
Full Name
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First Name
Last Name
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5
Address
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Street Address
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City
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Postal / Zip Code
Seleccione
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Macau
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Malawi
Malaysia
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Malta
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Palau
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Panama
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Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
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eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Otro
Seleccione
Seleccione
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Otro
Country
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6
Phone Number
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Area Code
Phone Number
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7
What is your Email?
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8
What's your Instagram?
We will only use this to send client photos, or tag client in photos.
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9
Who is your Piercer?
*
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Select the artist doing the tattoo.
Brooke Santos
Brooke Santos
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10
Which are you getting?
Single Piercing
Multiple Piercings
Jewelry removal
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11
What kind of jewelry are you being pierced with today?
Implant grade: Steel/Titanium
14k Gold
Implant grade: Steel/Titanium
14k Gold
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12
Please describe the Piercing the best you can.
*
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(EX: Left ear lobe, Right conch or jewelry removal or change)
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13
Location on body?
*
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(EX: Left Ear, Right bottom lip)
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14
How did you hear about us?
Google search
Instagram
Friend/Family
In the area
Other
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15
May we contact you via phone?
We will only contact you regarding appointments or follow-ups.
Yes
No
Text preferred
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16
Do you feel well today?
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Yes
No
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17
I do not suffer from any of the following conditions: Diabetes, epilepsy, hemophilia, a heart condition, nor do I take blood-thinning medication. I do not have a history of diabetes; hemophilia (bleeding); history of skin diseases, skin lesions, or skin sensitivities to soaps, disinfectants etc; history of allergies or adverse reactions to pigments, dyes or other sensitivities; history of epilepsy, seizures, fainting or narcolepsy; a history if use of medications such as anticoagulants which thin blood and interfere with clotting; or any other conditions such as hepatitis or HIV. I do not have any other medical conditions or skin conditions that may interfere with the application or healing of the piercing. I am not the recipient of an organ or bone marrow transplant, or if, I am, have taken the prescribed preventative regimen of antibiotics that is required by my physician in advance of this piercing. I am not pregnant or nursing. I do not have a mental impairment that may affect my judgement in getting the piercing.*
*
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I DO NOT suffer from a condition.
I DO suffer from a condition.
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18
*
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I AM NOT under the influence of alcohol or drugs, and I am voluntarily submitting to be Pierced by the Artist and BENCHMARK TATTOOS LLC without duress or coercion.
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19
*
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I acknowledge that I have truthfully represented, with a photo ID to the Piercer and BENCHMARK TATTOOS LLC, that I am at least eighteen (18) years of age or older, and that this information is true and correct.
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20
*
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I UNDERSTAND that a piercing is a permanent change to my appearance and that the skin cannot be returned to it’s original, unpierced appearance.
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21
*
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The Body art practitioner and BENCHMARK TATTOOS LLC have given me instruction on the care of my piercing while it’s healing; and I understand them and will follow them explicitly. I acknowledge that it is possible that the piercing can become infected, particularly if I do not follow the instructions given to me. If any corrective work to the piercing is needed due to my own negligence, I agree that the work will be done at my own expense.
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22
*
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I AGREE that I have been fully informed of the inherent risks associated with getting a piercing. I fully understand that these risks, known and unknown, can lead to injury, including but not limited to, infection, scarring, and allergic reactions (including materials involved in the piercing process such as latex gloves, soap, etc.) Having been informed of the potential risks associated with getting a piercing, I still with to proceed with the piercing process and I freely accept and expressly assume any and all risks that may arise from piercing.
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23
*
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ACKNOWLEDGE that both the Practitioner and BENCHMARK TATTOOS LLC have given me the full opportunity to ask any and all questions about the application of my piercing and furthermore the piercing process; and all of my questions have been answered to my total satisfaction.
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24
*
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I AGREE to reimburse each of the Practitioners and BENCHMARK TATTOOS for any attorneys’ fees and costs incurred in any legal action I bring against either the practitioner or BENCHMARK TATTOOS LLC and in which either the Practitioner or BENCHMARK TATTOOS LLC is the prevailing party. I agree that the courts of Massachusetts 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.
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25
*
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TO WAIVE AND RELEASE to the fullest extent permitted by Massachusetts Law each of the artists, owners, practitioners, corporate officers, employees, apprentices, assignees, independent contractors, and successors, and the BENCHMARK TATTOOS LLC, from any and all liability whatsoever, for any and all claims or causes of action that I , my estate, heirs, executors or assignees may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise from the application of my piercing, whether caused by the negligence or fault of either the practitioners, or BENCHMARK TATTOOS LLC.
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26
Please take a snapshot of your photo ID by clicking the button below.
*
This field is required.
Please ensure the entire ID fits in the photo. If under the age of 18 years old, original birth certificate, Parents Photo ID, and Child's Photo ID required.
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27
I have reviewed, understood, and agreed to the policies and requirements of BENCHMARK TATTOOS LLC, and hereby give my consent to BENCHMARK TATTOOS LLC to perform the tattoo work on my person. I have received and agree to follow all aftercare instructions.
*
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