CONSENT FORM

Patron's Name

Patron's Age

Preferred Pronouns

Patrons's Date of Birth

Date

Patron's Address

Patron's City & Zip Code

Patron's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Patron's Drivers License Number

Take Photo of State Issued ID

Take Selfie to match ID

Are you pregnant?

Are you currently or have you ever used medications that contain a controlled substance?

Have you been diagnosed with jaundice within the past twelve months?

Have you ever been diagnosed by a medical doctor as having allergies, not including seasonal allergies?

If Yes, what specific allergies?

Are you currently using any medications that contain blood thinners?

Are you currently using any medications that weaken the immune system that fights infections?

Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?

Have you ever been diagnosed by a medical doctor as to having contracted communicable disease such as Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and/or other blood borne pathogens?

If yes, when was your diagnosis and what is your current status?

I, Full Name* acknowledge by signing this writing that I have been given the full opportunity to ask any and all questions which I might have about the obtaining of a tattoo or body piercing from St. Louis Ink Tattoo Studio and that all of my questions have been answered to my full and total satisfaction.

I specifically acknowledge that I have been advised of the facts and matters set forth below, and I will agree as follows: acknowledge that I am aware certain medical conditions and treatments and/or medications used to treat those conditions medical be adversely impacted by the procedure(s) of tattooing and/or body piercing and/or branding. Such medical conditions include but are not limited to, may impaired kidney and/or liver function, diabetes, jaundice, medication containing blood thinners and medications that weaken the immune system.

Furthermore, I acknowledge that it is not reasonably possible for the representatives and employees of St. Louis Ink Tattoo Studio to determine whether l might have an allergic reaction to dyes, pigments, or any processes used in my tattoo, and I agree to accept the risk that such a reaction is possible.

I acknowledge that infection is always possible as a result of the obtaining of a tattoo or body piercing, particularly in the event that I do not take proper care of my tattoo. I acknowledge that variations in color and design may exist between any tattoo as selected by me and as ultimately applied to the body.

I further acknowledge that the tattoo and/or brand should be considered permanent; that said tattoo and/or brand can only be removed with a surgical procedure; and that any effective removal may leave permanent scarring and disfigurement. I acknowledge that the obtaining of my tattoo or body piercing is by my choice alone and I consent to the application of the tattoo or body piercing and to any actions of conduct of the employees of St. Louis Ink Tattoo Studio reasonably necessary to perform the tattoo and body piercing procedure.

I agree to release and forever discharge and hold harmless St. Louis Ink Tattoo Studio and it's agents, employees, officers, and shareholders from any and all claims, damages or legal action arising from or connected in any way with my tattoo and body piercing or the procedures and conduct used to apply my tattoo and body piercing.

I have read this form and confirm that all the information I have given is correct. I understand that this is a consent form and I agree to be legally bound by it

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SIGNATURE OF PATRON

DATE

Date

Patron's Information

Patron's Medical Assesment

To be completed by Patron