Tattoo Consent Form

Name*

First NameLast Name

Age*

Birth Date*

Date

Phone Number*

Email

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Where at (on body) and what kind of tattoo (Design) are you getting? *

How did you hear about Therapeutic Ink, LLC? *

Is this your first tattoo?*

YesNo

Are you currently (meaning today) using any recreational drugs (including Marijuana) or under the influence of alcohol or any other substance?*

YesNo

Have you ever fainted during a tattoo, a medical procedure involving needles, or just generally fainted?*

YesNo

Have you eaten in the past 2 hours?*

YesNo

Do you have Allergies?*

YesNo

FEMALE ONLY: Are you pregnant or nursing?*

YesNo

Do you have HIV, Aids, Hepatitis (any strain) or any other blood-borne illness?*

YesNo

Do you have or have a history of having MRSA/Staph *If Yes please identify below**

yesNo

Do you use or have you taken any medication or anticoagulants or other medical medications that may thin the blood and/or interfere with blood clotting?*

YesNo

Do you have Epilepsy, Narcolepsy or any other seizure disorder?*

YesNo

Do you have high blood pressure, diabetes, bleeding disorders, heart problems(cardiac valve disease), cold/flu, etc.*

YesNo

Health Problems: (please let us know if you are currently sick, or have high BP, diabetes, bleeding disorders, heart problems, cold/flu, HIV/AIDS, Hepatitis (any strain) or any other blood-borne illness. Please let us know if you have Epilepsy, narcolepsy, or any other seizure disorder.)

If yes, please identify the condition

Allergies: Please list everything you have an allergy to (e.g. latex, medical adhesives, peanut allergies, etc.)

If yes, please identify the allergy

Skin conditions: Please let us know if you have any rashes, eczema, infections, psoriasis, freckles, etc. Please also let us know if you've ever had or are currently experiencing a Staph infection, MRSA, or any other skin infection.

If yes, please identify the condition.

I am the person on the legal ID presented as proof I am at least 18 years of age or older and the said person on the ID.*

I state that I am of the age of eighteen (18) to receive a tattoo. I acknowledge that I am of age, and Therapeutic Ink, LLC is not responsible for further identification. If I lie about my age, Therapeutic Ink, LLC is not responsible for my well-being. If I sign and I am not the stated age, Therapeutic Ink, LLC has the right to legally pursue action against me. The below signature releases staff and associated parties from any legal responsibility re: age*

If I am under the age of 18, I have the presence and permission of my parents or guardian to receive the body art modification (***a parent or legal guardian is required to attend the appointment and provide a written consent and photo ID as well for minors under the age of eighteen (18)***).

I understand that getting a tattoo is a delicate process in which needles puncture the skin and inject ink and this can be a painful process, everybody responds differently to the procedure. I affirm and agree that it is unreasonable to think the artist know how I will respond to the procedure and I hereby agree to immediately let my artist know if I am in too much pain or if the procedure is too uncomfortable so that the artist can adjust, if necessary, allow me a break, or stop the procedure all together.*

I am not under the influence of alcohol/drugs of any kind. I am voluntarily submitting myself to receive the body art without duress or coercion*

I agree that if I use a numbing cream or any other 3rd party product, I do so at my own risk, assuming all responsibility for any reaction or poor healing and sacrificing my free touch-up. Therapeutic Ink will not do free touch-ups on a tattoo that healed poorly due to numbing cream.*

I am aware that tattoo inks, dyes, and pigments used on the procedure site have not been tested by the FDA, and the health consequences of using these products are unknown. I am also aware Variations in color and design may exist between the tattoo art I have selected and the actual tattoo when it is applied to my body. I also understand that over time, the colors and the clarity of my tattoo will fade due to unprotected exposure to the sun and the naturally occurring dispersion of pigment under the skin.*

I understand that this procedure is a permanent change to my skin and body.*

Photography: I release all rights to any photographs taken of me and the tattoo and give consent in advance to their reproduction in print or electronic form. *

I understand that the Tattoo Studio has a NO-REFUND policy on tattoos and/or retail sales and I will not ask for a refund for any reason whatsoever.*

I agree that any touch-up work needed, due to my own negligence, will be done at my own expense.*

I am aware of the signs and symptoms of infection, including, but not limited to redness, swelling, tenderness of site ,red streaks going from procedure site towards the heart, elevated body temperature or purulent (pus) drainage from site.*

I acknowledge that infection is always possible as a result of obtaining a tattoo, particularly in the event that I do not take proper care of my tattoo. I acknowledge that I have received aftercare instructions or have previously reviewed them via www.therapeuticinkgj.com or via Therapeutic Ink's Facebook Page and I agree to follow them while my tattoo is healing.*

I will seek professional medical attention at the first sign or symptoms of infection occur, at my own expense, and will indemnify and hold harmless the Therapeutic Ink from any charges or costs associated with seeking medical treatment*

If I have any condition that might affect the healing of this tattoo, I have advised my tattoo artist and still wish to proceed with the tattoo.*

I acknowledge that I am not pregnant or breast feeding at this time and understand the risks and complications should I be untruthful and agree to hold harmless the artist, shop, owners, agents and shareholders*

I DO NOT have medical or skin conditions such as but not limited to: acne, scarring, eczema, psoriasis, moles or sunburn in the area to be tattooed that may interfere with said tattoo. I also acknowledge that I DO NOT have any communicable disease such as HIV-AIDS, HEP.A/B/C, or any other strains, etc.*** If l do have any of the above or other infections or rashes anywhere on my body, I will advise my tattoo artist immediately if I have not done so already.****

I understand that the time quote for my tattoo is a best estimate and that I will be charged the hourly rate or price agreed upon. My artist will do their best to keep to the schedule. I understand that they will be focused on giving me the best tattoo possible and will be happy to schedule another appointment to finish my tattoo if needed. I also understand that I will need to pay for any additional sessions needed.*

I understand that any medical information obtained will be subject to the federal health insurance portability and accountability act of 1996 (HIPAA).*

I agree that I will not hold Therapeutic Ink, LLC or any of its artists or agents responsible for the work performed on me by any of the artists and acknowledge that this is the tattoo I have requested (I have seen the artwork and/ or the stencil when it was placed on my body and have acknowledged that all spelling is correct, this is the artwork I requested, and I have asked any and all questions) and if I am not sure, I will communicate that to my artist.*

I acknowledge that I DO NOT have any physical, mental, or medical impairment or disability which might affect my wellbeing as a direct or indirect result of my decision to have a tattoo done at this time.*

I acknowledge it is not reasonably possible for the representatives and employees of this tattoo shop to determine whether I might have an allergic reaction to the pigments or processes used in my tattoo, and I agree to accept the risk that such a reaction is possible and hold harmless the tattoo shop, artist and agents should one occur.*

I agree and understand that there is a chance I might feel lightheaded and/or dizzy during or after being tattooed, I will immediately let my artist know of these feelings. I have further identified whether I have fainted or felt dizzy previously. *

I agree and understand that Therapeutic Ink, LLC and the artists are NOT responsible for the meaning or spelling of the symbol or text that I provide them or chosen from Flash Sheets or any other designs and I have thoroughly did my own research before requesting such design.*

I agree and understand that Therapeutic Ink, LLC and the artists are not medical professionals. Any suggestions made to me are NOT to be construed as or substituted for advice from a medical professional.*

I understand the permanent nature of receiving body art and that removal can be expensive and may leave scars on the procedure site and the only way to have it removed would be with surgical laser procedure.*

I acknowledge and agree that once I leave Therapeutic Ink the body art is my responsibility and agree to hold the artist and Therapeutic Ink harmless of any and all claims after my departure from the shop. *

I acknowledge and agree that should I have any questions, concerns, or complaints I agree to reach out to my artist via telephone or private message to discuss the issue at hand to discuss.*

I acknowledge that the information I have provided in the medical questionnaire is complete and true to the best of my knowledge.*

Legal Action: I agree to reimburse each of the Artists, agents, and Therapeutic Ink LLC for any and all attorneys fees and costs incurred in any legal action I bring against either the Artist or the Tattoo Studio and in which either the Artist or the Tattoo Studio is the prevailing party. I agree that the that the courts of Colorado shall have personal jurisdiction and venue over me and shall have exclusive jurisdiction for the purpose of litigating any dispute arising out of or related to this agreement.*

After reading this consent and waiver form I fully consent to the application of the tattoo and to any and all actions or conduct of the representatives and employees of Therapeutic Ink that are reasonably necessary to perform the tattoo procedure.*

ALL QUESTIONS ABOUT THE BODY ART PROCEDURE HAVE BEEN ANSWERED TO MY SATISFACTION AND I HAVE BEEN GIVEN AFTERCARE INSTRUCTIONS OR HAVE REVIEWED THEM ELECTRONICALLY. I AGREE TO RELEASE AND FOREVER DISCHARGE THE ARTIST PERFORMING THE BODY ART AND THERAPEUTIC INK, LLC, AND FOREVER HOLD HARMLESS THE SHOP, ARTIST, OWNER, ASSOCIATES, AGENTS, OFFICERS, SHARE HOLDERS FROM ANY AND ALL CLAIMS, DAMAGES, OR LEGAL ACTIONS RISING FROM OR CONNECTED IN ANY WAY WITH MY BODY ART OR THE PROCEDURES AND CONDUCT USED TO APPLY MY BODY ART AND ANY AND ALL BODY ART APPLIED BY ITS ASSOCIATES, AGENTS, AND REPRESENTATIVES IN THE FUTURE.*

I, First Name* Last Name* (PRINT NAME) DO HEREBY STATE THAT THE INFORMATION I HAVE PROVIDED IS COMPLETE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. I HAVE BEEN FULLY INFORMED OF THE RISK OF TATTOOING INCLUDING BUT NOT LIMITED TO INFECTION, SCARRING, DIFFICULTIES IN DETECTING MELANOMA AND ALLERGIC REACTIONS TO PIGMENTS, LATEX/NITRILE GLOVES, AND ANTIBIOTICS. HAVING BEEN DULY INFORMED OF THE POTENTIAL RISKS ASSOCIATED WITH GETTING A TATTOO, I STILL WISH TO PROCEED WITH TATTOO APPLICATION AND I ASSUME ANY AND ALL RISKS THAT MAY ARISE FROM TATTOOING.

If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.

Signature

Signed Date*

Date

Please add a photo of you ID/Driver License Here*

Tattoo Consent Form

Client Information

Pre-Procedure Questionnaire

Acknowledgment and Waiver