Studio Berkana Tattoo Consent Form

Client Information

Tattoo consent form
Client Name*

First NameLast Name
Gender*
Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Person*

First NameLast Name
Emergency Contact Phone Number*
Drivers License or Government ID*

Please upload photo of your Government Id
Cancelof
Are you under the age of 18? yes or no*
If yes please upload copy of Birth Certificate

If you are a minor you MUST have your birth certificate and legal guardian present with ID
Cancelof

Medical / History Data
Do you have any of the following conditions?

HypertensionHeart issuesRashesDiabetesProblems healing woundsIssues blood Clooting or history of hempheliaHistory of keloid scarringHistory of cold sores or fever blistersHistory of anemiaSeizureSpinal Cord IssuesHistory of skin disease or skin sensitivity
Are you pregnant, breastfeed, or nursing? (Female)*

YesNo
Are you currently taking any medications? If yes, please list them below:
Technicians make no attempt to, or claim to, practice medicine. Some individuals will have complications related to permanent make-up/tattoo applications. These complications are usually mild and last only a few days. However, extreme complications are always a possibility.
Authorization
- I confirm that all information given in this form is true, complete, and accurate.
- I agree to comply with all instructions given by the tattoo artist regarding the care of the tatoo.
- I understand and acknowledge that the process of tattooing involves piercing the skin with a needle(s) and may cause pain, discomfort,swelling, and bleeding.
- There is a possibility of an allergic reaction to the ink, and have informed the tattoo artist of any known allergies or medical conditions that may affect the tattoo process.
- The tattoo artist has explained the risks of infection associated with the tattoo process and has provided instructions for proper aftercare.
- I hereby release Studio Berkana and any independent contractors working out of Studio Berkana for any and all liability, including but not limited to: injury, infection, allergic reaction, or damage to personal property that may arise as a result to the tattoo process.
- I certify that I am 18 years of age or older and have provided a valid form of identification.
I have read and understand the contents of each paragraph above. I acknowledge 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 aforementioned procedure(s). I further acknowledge that at the time of signing this consent to this procedure(s), I was of sound mind and capable of making independent decisions for myself.
Studio Berkana and its Independent Contractors shall perform permanent application of dyes to the skin of the releaser. I hereby release, acquit and discharge Studio Berkana and its Independent Contractors and any and all persons which are or might be claimed to be liable to me from all claims and demans or whatever nature, actions and causes of action, damages, cost, loss of service, expenses and compensation on account or in any way growing out of personal injuries and property damage to result at any time in the future, whether or not they are in contemplation of parties at the present time and whether or not they arise following the execution of the release as the as the result of treatment procedure rendered. Releaser agrees to indemnify the hold harmless of Studio Berkana and Independent Contractors for any loss, damage, claim, injury, or expense asserted against myself.
Signature of the Client*

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Date*

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The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to be spread mainly from person-to-person contact. As a a result provincial and federal health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups and people.

Studio Berkana has put in place preventative measures to reduce the spread of COVID-19 with strict cleaning measures and a strong recommendation to wear masks during appointments if possible. Further, attending to appointments in the studio could increase your risk of contracting COVID-19.

By signing this agreement, I acknowledge the contagious nature of COVID-19 by attending the appointment and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed or infected by COVID-19 at MicroBeauty Studio may result from the actions, omissions, or negligence of myself and others, including, but not limited to, employees, volunteers, and program participants and their families.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my family may experience or incur in connection with my attendance at Studio Berkana
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Client Information

Medical / History Data

Authorization