Amber Moon Tattoo
Consent and Release Form
Client Information
Please complete prior to appointment only
Full Name
*
First Name
Last Name
Preferred name/pronoun(s)
Age
*
Date of Birth
*
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Month
-
Day
Year
Date
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Artist today
Please answer the following questions honestly:
I consent to being tattooed today. I understand that a tattoo is a permanent change to my appearance. I understand that no claims have been made as to the ability to change or remove/reverse this change at any point in the future.
*
Agree
Disagree
I am not pregnant or breast-feeding.
*
Agree
Disagree
I am not under the influence of drugs or alcohol?
*
Agree
Disagree
I have eaten in the last 3 hours.
*
Agree
Disagree
I agree to inform my artist of any potential skin issues that I may have prior to being tattooed. This includes, but is not limited to, sunburn, moles, scars, rashes and wounds. (if yes, please list in field further down this form)
*
Agree
Disagree
I understand that there is a risk of adverse/allergic reaction to the practices and products used in the tattooing process today. I agree to inform my artist of any allergies/sensitivities prior to the procedure. (there is a place to list allergies below).
*
Agree
Disagree
I understand that there may be side effects from this procedure, including but not limited to, pain, swelling, bruising, scarring and discoloration.
*
Agree
Disagree
I do not have any conditions that compromise my immune system or my ability to heal my new tattoo.
*
Agree
Disagree
To my knowledge, I do not have any communicable disease.
*
Agree
Disagree
I do not suffer from hemophilia, epilepsy or any form of seizure disorder.
*
Agree
Disagree
I agree to follow the aftercare instructions given to me today. I understand that failure to follow these instructions may result in infection, poor healing, color loss, scarring and other issues.
*
Agree
Disagree
I give my consent to have photos taken of my tattoo. I understand that these photos will be used in various marketing and social media platforms. I consent to the use of these photos by Amer Moon Tattoo, @katecooktattoos and any of their subsidiaries.
*
Agree
Disagree
Skin conditions (e.g. Rashes, eczema, scars, sunburn, psoriasis, freckles, etc.)
*
Type N/A if none (only the area to be tattooed needs to be considered)
Allergies (please list ALL known allergies)
*
Type N/A if none
Please list all medications
*
Type N/A if none
Acknowledgment and Waiver
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I acknowledge that both written and verbal instructions regarding aftercare have been provided to me. I understand these instructions and agree to follow them.
*
I agree that touch up work needed due to my own negligence will be at my own expense.
*
I understand that infection and/or allergic reaction is always a possibility when getting a tattoo.
*
I understand that my tattoo may fade, dull and spread over time. I acknowledge that this is a natural part of the the process and is not the responsibility of Amber Moon Tattoo, it's owner, associates and affiliates.
*
I acknowledge that this is a non-refundable service. There are no refunds/exchanges/credits for any reason.
*
I consent to any reasonable actions and/or conduct of the representatives and employees of Amber Moon Tattoo necessary to perform the procedure.
*
I understand that there are video cameras in the space I am being tattooed in. These cameras are used/viewed for security purposes only. The are there for both of our safety. Video footage is not shared or public in anyway.
*
I agree to release and hold harmless Amber Moon Tattoo, it's owner, contractor and affiliates from any liability or loss as a result of my decision to be tattooed today. I agree to not sue, harass or negatively represent Amber Moon Tattoo, it's owner, contractors and affiliates as a result of my decision to be tattooed today.
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I acknowledge that I have been given the opportunity to approve my design and ask any and all questions I may have. I consent to be tattooed today.
*
I confirm that the information I provided in this document is accurate and true.
Signed Date
*
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Month
-
Day
Year
Date
Client Signature
*
Please take a picture of your drivers license
Submit
Should be Empty: