Tattoo Consent Form- Studio Noir

Please be advised that your artist is obligated to perform procedures in strict compliance with all hygiene and health protection measures. The information you will provide is confidential and it shall also be handled in that way.
Name*
Pronouns*
Legal Name (if differs from above)
Who is your tattoo artist? *
DOB*
Address*

Address

Street Address Line 2

CityState

Postal / Zip Code
Zip*
Phone Number*
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Who referred you?
Photo ID*

Upload a copy of your current photo ID
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Symptoms of COVID-19 may appear 2-14 days after exposure to the virus. People with these symptoms are prohibited from entering the premises.

In order to ensure the health and safety of our staff and clients, please answer the following questions truthfully and to the best of your knowledge. Your responses will be kept confidential.
Please indicate if you are experiencing any of the following symptoms

Fever or chillsCoughShortness of breath or difficulty breathingFatigueMuscle or body achesHeadacheNew loss of taste or smellSore throatCongestion or runny noseNausea or vomitingDiarrhea
Proof of Vaccination*

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Tattoo is not a suitable procedure for everyone. In order to find out if you are fit for this procedure, please answer the following health questions truthfully. Studio Noir and its practitioners will assume no liability in the event you give false information to obtain the treatment.

Do you have any of the following conditions or are you taking any of these medications?
Allergies

DiabetesSkin ProblemsHemophiliaScarring (Keloids)Eye ProblemsAllergiesMoles or Freckles at Site of TattooHeart ProblemsCancerEpilepsyHepatitisHIVCold SoreCardiac Valve DiseaseHerpes infection at the proposed procedure site?Blood thinning medications
Other: Please explain

Other: Please explain:
If you checked any of the boxes, please explain more here:
Please read and check each box below.*

Tattoo is an art and not a science. Client's result will vary.Tattoo always leads to skin injury. Therefore, it is important to carefully and gently nurture your skin after treatment to allow for healing without complications. Inadequate care in the healing phase can lead to poor results and Studio Noir and its practitioners cannot be held accountable for it.
I am aware that the results can be affected by: medication, skin type, smoking, activities which cause sweating, drug and alcohol use, and other factors.During the healing period redness, swelling, scabbing of the skin, irritation, itching, minor bleeding, and other effects are possible. I understand that the FDA does not approve any pigments used for this procedure and that the health effects are unknown.I agree to release and forever discharge and hold harmless the Artist and all employees of Studio Noir from any and all claims, damages, or legal actions from or connected in any way with my tattoo and the procedure and conduct used in my tattoo.I understand that THE TATTOO ARTIST DOES NOT ACT AS A MEDICAL PROFESSIONAL. Any suggestions made to me are NOT to be construed as/or substituted for advice from a medical professional.I acknowledge I am over the age of eighteen and that I have truthfully represented to my artist that the application of a tattoo is by my choice alone.I consent to the application of the tattoo and to any actions or conduct of the representatives and employees of Studio Noir reasonably necessary to perform the procedure. I acknowledge that a tattoo is a change to my appearance and that no representations have been made to me as to the ability to later change or remove my tattoo.
To my knowledge, I do not have any physical, mental or medical impairment or disability, which might limit my well being as a direct or indirect result of my decision to have this procedure. I understand that if I have any skin treatments, laser hair removal, plastic surgery, or other skin altering procedure that it may result in adverse changes to my tattoo.
I acknowledge that infection is always possible as a result of the obtaining of a tattoo, particularly in the event that I do not take proper care of my tattoo.I have received aftercare instructions and I agree to follow them while my tattoo is healing.I agree that any touch-up work needed, due to my own negligence, will be done at my own expense.I acknowledge that it is not reasonably possible for the representatives and employees of this studio to determine whether I might have an allergic reaction to the pigments or processes used in my procedure and I agree to accept the risk that such a reaction is possible.If I have a medical condition such as but not limited to: acne, scarring (keloid), psoriasis, freckles, moles or sunburn in the procedure area that may interfere with said procedure.I am informed that in case numbing topical cream is to be used, some sensitivity, discomfort, allergic reaction, redness, swelling, and other reactions are possible, depending on my skin type and sensitivities.The following conditions require consent from a supervising physician. If I have any of the following conditions I will provide my Artist with a letter of consent from my physician: Diabetes, HIV, hepatitis, high blood pressure, thyroid disease, hemophilia, leukemia, anemia and any other blood disorders, any type of cancer, pregnancy, nursing, and any type of liver disorders.I approve of the shape and design created by my tattoo artist and I give my consent to use a tattoo machine to apply pigments to the skin.I am not pregnant or nursing.
In case I will need an MRI scan I will notify and discuss my permanent makeup procedure with my health provider/doctor.I grant my tattoo artist the irrevocable, perpetual, and exclusive right and permission to use photographs/video of me for all media throughout the world including print, internet, other electronic media.
I acknowledge and give my permission that such images and digital files may be made public on the Internet and I might be identified. I release and waive any current and future claims, demands, actions, causes of actions, suits, costs, liabilities, damages against Studio Noir, my practitioner, its employees, owners, directors, officers and trustees for the right of privacy and publicity violation and invasion, intrusion of soltitude and seclusion, public disclosure of private facts, health record protection violations, false light, appropriation of the name or likeness, tort of defamation, commercial exploitation and other privacy related rights violations. waive my right to approve the changes and final result and give my consent to the editing, retouching and modifying. I agree that my practitioner owns the property rights for such images, digital files, and materials.
I acknowledge by signing this agreement 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 permanent makeup treatment and that my questions have been answered to my full satisfaction.
I consent to my temperature being taken.Receiving a COVID-19 vaccine two weeks before and after my procedure may cause an adverse reaction in the treated areas
Signature*

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Date*

MonthDayYear
The following is for your technician, please press submit.
For Technician: Completed Tattoo Photo

Completed Tattoo Photo
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For Technician: Inks and Needles Used
Brand, Size, Lot, Expiration date
Should be Empty: