CONSENT TO TATTOO

Date

Name

First NameLast Name

Email

example@example.com

Phone Number

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

Age

Date of Birth

Date

Location of Tattoo on Body

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Upload image of your ID

I acknowledge by signing this release that I have been given the full opportunity to ask any and all questions which I might have about obtaining a new TATTOO from ________________ (hereafter called “Tattooer”) and that all of my questions have been answered to my full and total satisfaction.

I acknowledge that obtaining this tattoo is my choice alone and that needles and tattoo ink will go into my skin and will result in a permanent change to my appearance, and that no representations have been made to me as to the ability to later restore the skin involved in piercing to its pre-tattoo condition, and it can be costly to remove. (initial your name)

I am not pregnant or nursing. I do not have any history of herpes infection at the proposed procedure site. I do not have epilepsy, diabetes, and allergic reaction to latex or antibiotics, hemophilia or other bleeding disorders. I do not have cardiac valve disease or suffer from any heart conditions or take medications, which thins my blood. (initial your name)

If I suffer from hepatitis, or other risk factors for bloodborne pathogen exposure, or any other communicable disease, I have informed the Tattooer of the fact and have been advised of any medications and/or procedure necessary to promote the satisfactory healing of my tattoo. Please advise the Tattooer if you are an organ recipient. (initial your name)

I do not suffer from any medical or skin condition(s) such as, but not limited to: keloid or hypertrophic scarring, psoriasis at the site of the tattoo, or any open wounds or lesions at the site of the tattoo. I understand that having a tattoo may make it more difficult to identify skin conditions, such as cancer, and I still wish to be pierced. (initial your name)

I have advised the Tattooer of any allergies to latex gloves, soaps, or medications. I acknowledge it is not reasonably possible for the Tattooer to determine whether I might have an allergic reaction to the tattoo ink or with the process involved in the tattoo and further acknowledge that such reaction is possible. (initial your name)

I have truthfully represented to the Tattooer that I am 18 years of age or older. I am not under the influence of any drugs or alcohol. To my knowledge, I do not have any physical, mental, or medical impairment or disability that might affect my well being as a direct or indirect result of my decision to have a tattoo at this time. (initial your name)

I do not have a history of medication use and am not currently using medication, including being prescribed antibiotics prior to dental or surgical procedures. (initial your name)

I acknowledge infection is always possible as a result of obtaining a tattoo, and I agree to follow all suggested instructions concerning the care of my tattoo, while it is healing. (intial your name)

I acknowledge that a tattoo may itch, scab, and flake during the healing process, and requires special care for proper healing. Aftercare instructions have been provided, and I agree to follow the instructions. (initial your name)

I acknowledge and give consent to Parlor SIX8 and a third party to use images or videos of my tattoo(s) for marketing and, or publishing purposes in various media such as the internet, magazine, printed, and or television, etc. (initial your name)

I understand I will be tattooed using appropriate instruments and sterilization techniques. Therefore, I request the Tattooer to tattoo me. (initial your name)

I understand that the tattoo usually takes 2-6 weeks or longer to heal. I agree to release and forever discharge, and hold harmless, the Tattooer, all employees, and contractors from any and all claims of negligence, damages, or legal actions arising from or connected in any way with my tattoo, the procedure, and conduct used in my tattoo and assume all responsibility for the decision(s) made consenting to this permanent procedure.(initial your name)

I understand that inks, dyes, and pigments have not been approved by the federal Food and Drug Administration and that the health consequences of using these products are unknown. (initial your name)

Signature