LAST MATCH TATTOO LOUNGE CUSTOMER WAIVER FORM
Are you a returning client?
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Yes
No
Name
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First Name
Last Name
What would you like us to call you?
Pronouns:
Date Of Birth
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-
Month
-
Day
Year
Date
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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example@example.com
Please take a photo or upload a file (below) of the FRONT of your ID/Drivers License/Passport, making sure all information is clearly visible.
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Tattoo Description:
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Tattoo Placement:
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Artist's Name:
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Charlie d'Eve (@charliedeve.tattoo)
Guest Artist
If Guest Artist, Guest Artist's Name:
By checking this box, I agree that I am not under the influence of alcohol or any other intoxicating substances.
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I am not under the influence of alcohol or any other intoxicating substances.
By checking this box, I certify that I am 18 years of age or older. I will provide identification to verify my age. I understand that I am liable for criminal prosecution if I misrepresent my age with false information or documentation.
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I certify that I am 18 years of age or older.
Medical History
Please note that the following questions are only to make sure we accommodate you as necessary during your tattoo appointment.
Do you have any allergies or sensitivities to the following:
Latex
Medicines
Topical solutions such as soap, alcohol, disinfectants
Adhesives
I have no known allergies or sensitivities
Do you have any skin conditions?
Psoriasis
Eczema
Scars in the area to be tattooed
Acne in the area to be tattooed
I have no known skin conditions
Are you Hemophiliac, prone to heavy bleeding or taking blood thinner medication?
Yes
No
Are you pregnant? (Oregon State Law prohibits the tattooing of a person while they are pregnant.)
Yes
No
Do you have any of the following medical conditions?
Diabetes
High Blood Pressure
Low Blood Pressure
Anemia
Please INITIAL the below statements.
I understand that tattoos will permanently change my appearance. I realize that all bodies are unique and therefore tattooing results may vary. I authorize Last Match Tattoo, their artist or representative to apply a tattoo to my body and hereby release them from all liabilities, claims, actions and demands.
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I understand that I will be tattooed using instruments and techniques selected by Last Match Tattoo. To ensure proper healing of my tattoo, I agree to follow the aftercare procedures outlined in the aftercare instructions provided to me, either verbally or physically, until healing is complete.
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I understand that the employees and/or private contractors of Last Match Tattoo are not medical professionals. Any suggestions made by a representative of Last Match Tattoo will not be construed as, or substituted for, medical advice from a physician.
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I understand that complications, including but not limited to: scarring, loss of color/pigment, infections, allergic reactions (to ink, ointment, soaps, or instruments), and differing results of brightness/color because of skin type/tone/age are a possible outcome of the tattooing and healing process.
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By my signature, I certify that I have read and understood this agreement. All of my questions have been answered to my satisfaction. I accept the risks and will not hold Last Match Tattoo, its representatives or artists, responsible. I freely consent to the tattoo procedure.
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Please enter date.
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Month
-
Day
Year
Date
By checking this box, I agree to have my photo taken. This photo can be used for, but not limited to the following: Digital and physical portfolios, limited advertisement and promotional materials online and physical media.
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I agree to have my photo taken.
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