Mikel Ink Tattoo Consent Form
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DRIVERS LICENSE OR ID NUMBER
*
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
I am currently over the age of 18
*
Yes
Please describe what tattoo you are getting and the location on your body:
The nature and method of the proposed fine line single needle tattoo procedure has been explained to me as having the usual risks inherent in the procedure and the possibility of complications during and following its performance. I understand that there may be a certain amount of discomfort or pain associated with the procedure and that other possible adverse side effects may include: minor and temporary bleeding, bruising. redness or other discoloration and or swelling. Fading or loss of pigment may occur. Secondary infection in the area of the procedure is rare if properly cared for but may occasionally occur.
*
Acknowledgement / Waver
*
I have informed the practitioner of any and all of my known allergies. I acknowledge that it is not always reasonably possible to determine in advance whether I might have an allergic reaction to any of the pigments, dyes, topical preparations, latex, iodine, or processes used in the procedure; and I agree to accept the risk that such reaction is possible.
I am not currently taking Accutane or any medications that could interfere with the healing of my tattoo.
I have informed the practitioner of any medical condition that may affect my ability to be a candidate for these services including hepatitis, diabetes, and/or jaundice in the last 12 months.
I acknowledge that complications as a tattoo procedure may occur. particularly in the event that the post-procedural instructions are not followed, and accept full responsibility for such complications.
I have not ingested blood thinners such as aspirin or ibuprofen within 24 hours prior to this appointment.
I have not consumed alcohol or other intoxicants at least 24 hours to this appointment.
I do not have any conditions that might affect the procedure or healing process such as lupus, diabetes, or hemophilia.
I have eaten at least 2 hours before this appointment.
I realize that my body is unique and neither the practitioner nor its employees or contractors can predict how my skin may react as a result of the procedure.
I acknowledge that the procedure may result in a long-lasting (many years) change to my appearance and that no representations have been made to me as to the ability to later change or remove the results.
I understand that future skin altering procedures such as laser treatments, plastic surgery, implants, and/or injections may alter and degrade my tattoo and that I must inform any future service provider that I have had a tattoo. I understand and accept that such changes are not the fault of the practitioner or its employees or contractors. I further understand that such changes or degradation in my appearance may not be correctable through further procedures.
I consent to the admittance of authorized observers to the procedure(s) for the purpose of education or assistance.
I acknowledge that obtaining the tattoo is my choice alone, and I consent to the procedure and to its attendant risks, and to any actions or conduct reasonably necessary to perform the procedure.
I understand that I will have the opportunity to approve the design and color of the tattoo to be applied, and I accept responsibility for the same.
I consent to any relevant photographs being taken before, during, and after the procedure, to document the results of the procedure and/or educational purposes for use of practitioners business.
I consent to the practitioner using "before & after" photos of me for marketing purposes to display its capabilities and results.
I have been given the full opportunity to ask any and all questions which I have about obtaining tattoo procedures from the artist and that all of my questions have been answered to my full and total satisfaction.
I understand that I need to follow the instructions given to me by the practitioner, Mikel Ink, and that failure to follow said instructions could result in an infection and could negatively affect the look of my tattoo.
I understand that I should seek out a medical professional should any infection / complications occur.
I ACCEPT THAT FAILURE TO FOLLOW THE POST-PROCEDURE INSTRUCTIONS MAY ALSO RESULT IN A LOSS OR DISCOLORATION OF PIGMENT RESULTING IN A NEED FOR MORE FREQUENT TOUCH-UPS. NO GUARANTEES, NO REFUNDS.
*
I have read and understand the contents of each statement above. I acknowledge that this is a contract and that I have received no warranties or guarantees with respect to the benefits to be realized from, or consequences of the before mentioned procedure(s). I further acknowledge that at the time of signing this consent I am of sound mind and capable of making independent decisions for myself. The information provided on this form is accurate and complete to the best of my knowledge, and that my practitioner is not responsible for complications or problems arising from any incorrect or omitted information.
*
Artist Signature (please give to Mikel so she can sign :)
*
Submit
Should be Empty: