MINOR TATTOO CONSENT FORM

I,   First Name*   Last Name*   , authorize a deposit for tattoo services performed by Emily Gee (technician). This deposit is in the amount of $deposit amount*, 50% of the cost of tattoo services performed on the date of the appointment, Date*.

By making this appointment, I understand the following:

All deposits are non-refundable.      Initials*   

The deposit quoted was for the specific size, placement, and references provided in the consultation. Any changes to size, placement, or imagery may result in additional deposits/charges.   Initials*   
     
Cancellation Policy: All clients must give 7 days notice if the appointment needs to be cancelled. If a client chooses to reschedule their appointment, the rate they received during their quoting is not guaranteed, and are responsible for all rate increases at the time of the new appointment.   Initials*   

Late Policy: Billing for services begins at the start time of the appointment. If a client arrives late, they are still responsible for paying for the entire appointment time without an extension of time. No-show appointments will still be charged for the entire appointment amount.    Initials*   

If a client forfeits their deposit due to lateness an additional deposit in the same amount will be required to rebook their appointment. Clients must sign and complete this form within (7) days of paying their deposit.     Initials*   

On the rare occasion that the technician cancels, a new appointment must be provided within a month of the initial deposit. Should the client not be available within those dates, a later date will be chosen and the deposit is transferred to the new appointment date.   Initials*   

The technician may decline services at their discretion based on health or appearance of health. Reasons for health related cancellations are: being under the influence of alcohol or illegal drugs, confirmation of a communicable disease, visible signs of illness, visible contagious skin diseases, positive COVID results, and/or impaired cognitive functioning.    Initials*   

I am the:    Please Select parent legal guardian *   
of    First Name   Last Name  
born on  Date* .

By signing this box, I am authorizing the tattoo technician to perform services on this minor, and that the minor is 16 years of age or older.     Initials*   

You must upload either a birth certificate or legal documentation proving that you are responsible for legal decisions on behalf of the minor below.

I,   First Name*   Last Name*   , agree to the following on behalf of   First Name*   Last Name*   :

I am aware of the risks associated with tattoo procedures. I understand that these risks, known and unknown, can lead to injury including but not limited to: infection, scarring, allergic reactions to tattoo pigments, latex gloves, and/or soap. I wish to proceed with tattoo procedure and freely accept all outcomes that may arise from tattooing. I waive and release the technician from all liability.  
Initials*   

The technician has given me full opportunity to ask any question about the tattoo procedure and application of my tattoo and all of my questions, if any, have been answered to my full and total satisfaction.  Initials*   

The technician has given me instructions on the aftercare of the tattoo. Tattoo aftercare instructions can be viewed here: Tattoo Aftercare. I acknowledge that infection is possible, particularly if I do not follow the instructions given to me. If any additional work to the tattoo is needed due to my own negligence, I agree that the work will be done at my own expense..Initials*   

The minor is not under the influence of alcohol or illegal drugs, and I am voluntarily submitting to be tattooed by the technician without duress or coercion.Initials*   

The minor does not suffer from diabetes, epilepsy, hemophilia, heart condition(s), nor do I take blood thinning medication. I do not have any other medical or skin condition that may interfere with the procedure, application, or healing of the tattoo. I am not the recipient of an organ or bone marrow transplant, or if I am, I have taken the prescribed preventative regimen of antibiotics that is required by my doctor in advance of any invasive procedure such as tattooing. I do not have a mental impairment that may affect my judgement in getting the tattoo. I have disclosed any and all medical conditions to my technician that may affect the tattoo procedure. Initials*   

The minor is not pregnant or nursing.*       

I release the right to any photographs/videos taken of me and the procedure and give consent in advance to their reproduction in print or electronic form.Initial*   

I agree that the technician has a no refund policy on tattoos, and will not ask for a refund for any reason whatsoever. Initials*   

I agree to reimburse the tattoo technician for any attorneys' fees incurred in any legal action I bring against the technician. I agree that the courts located in the County of Fairfield within the State of Connecticut shall have jurisdiction and venue over me and shall have exclusive jurisdiction for the purposes of litigating any dispute arising out of, or related to this agreement.Initials*   

I acknowledge that I have been given adequate opportunity to read and understand this document. I am signing a legal contract waiving certain rights to revocer damages against the technician. I understand that the technician has the right to terminate the appointment should the document should not be signed within (7) days of deposit payment without a refund.Initials*   

I declare that I am of legal age to make decisions on behalf of the minor. I declare that I am the parent or legal guardian of the minor and have provided both valid proof of age/identification above, as well as legal documentation (birth certificate/guardianship paperwork) and am competent to sign this agreement. 

First Name*   Last Name*   
Email*   
   Phone Number*   
Date*   
Date of Birth*   

Signature*   

The minor is allergic to:
Latex   Yes   No*   
Adhesive   Yes   No*   
Lidocaine/Numbing   yes   Tno 2