Form
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Photo ID
*
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I have no medical condition that prohibit me from getting tattooed
*
Please Select
Yes
No
I acknowledge that I am not pregnant
*
Please Select
Yes
No
I acknowledge that I am free from communicable diseases
*
Please Select
Yes
No
I acknowledge that I have been truthfully represented to the tattooist (Emma Tullett), that I am over the age of 18
*
Please Select
Yes
No
I acknowledge that infection is always a risk associated with tattooing, particularly if I do not take proper care of my tattoo
*
Please Select
Yes
No
I acknowledge that a tattoo is a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove my tattoo/s
*
Please Select
Yes
No
I acknowledge that the obtaining of my tattoo is by my choice alone and I consent to the application of the tattoo and to any actions or conduct of the tattoo artist deem reasonable and necessary to perform the tattoo procedure
*
Please Select
Yes
No
I agree to release and forever discharge and hold Emma Tullett from any and all claims, damages or legal actions arising from or connected in any way with my tattoo or procedures and conduct used to apply my tattoo
*
Please Select
Yes
No
I agree to give Emma Tullett Consent to post any/all photos of my tattoo/s
*
Please Select
Yes
No
I confirm that any and all, placement, spelling, and or translation decisions are mine and correct
*
Please Select
Yes
No
Tattoo idea and placement
Signature
*
Date
*
-
Month
-
Day
Year
Date
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