Consent Form

Consent and Release Form

Banner and Bone Tattoo Company 984 Kempton Street New Bedford MA 02470
Name*

First NameLast Name
Pronouns
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Date of Tattoo*

MonthDayYear
Date
Name of Artist*
Tattoo Description*
Tattoo Placement*
Please check the following conditions which apply to you:

Shellfish allergyLatex AllergyPregnantDiabetesHemophiliaAnticoagulant medicationHIVHepatitisEpilepsySeizuresHistory of faintingNarcolepsyMango AllergyNut Allergy
I consent to have my photo taken and accept that photographs can be used by Banner and Bone Tattoo Company for any electronic or print medium.

YesNo
Consent to application of Tattoo and Release/Waiver to any Claims

Upon signing this form, I accept that I have been given the opportunity to ask questions concerning the tattoo process. Its costs, possible risks, and aftercare that I accept that these questions were asked fully and to my satisfaction. I have also been given the opportunity to have a third-party present.

I understand that the following health conditions may increase health risks associated with getting a tattoo: diabetes, hemophilia, allergies or adverse reactions to pigments or dyes, epilepsy, seizures, fainting, narcolepsy, HIV, hepatitis, skin diseases, skin lesions, or skin sensitivities to soaps, disinfectants,ect., medications such as anticoagulants which thin the blood and/or intterfere with blood clotting.
Client Acknowledgement

1. I have read the information shown above.

2. I have been verbally informed by the practitioner providing the service of risks and dangers associated with receiving a tattoo.

3. I have been given the opportunity to have a third party present while receiving tattoo services.

4. I am not under the influence of drugs or alchol.

5. I accept responsibility for the aftercare of my tattoo as instructed by the tattoo artist and recognize improper care of my tattoo can result in infection or damage to it's appearance.

6. I release the tattooist, Banner and Bone Tattoo Company, their associates, or any and all applicable personnel frmo any and all claims, damages, or legal actions arising from or connected to my tattoo and its application.
Signature*

Clear
Date*

MonthDayYear
Date
Government ID *
Should be Empty:

Consent and Release Form