Tattoo Consent Form/ Symptom Screening

Name

FirstLast

Legal Name (if different)

FirstLast

Pronouns

Date of Birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Picture of Photo ID

Flash or Custom Design

Flash includes pre-drawn designs as is/pre-drawn designs with limited changes

Desired Placement of Tattoo (shoulder, back of the calf, etc)

(Please write "not sure" if applicable)

Accessibility needs/allergies/accommodation requests

Whatever you feel comfortable sharing that will make your experience safer/more enjoyable: sensitive to loud music, prefer limited conversation during tattoo, etc

I acknowledge I have been advised of the facts and matters set forth below and I agree as follows: If I have diabetes, epilepsy, hepatitis, hemophilia, HIV-AIDS or any other communicable disease, heart condition or take medicine which thins the blood I have advised my tattooer.I am not pregnant or nursing. I am not under the influence of alcohol or drugs. I acknowledge it is not 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. I acknowledge that infection is always possible as a result of the obtaining of a tattoo, particularly in the event that I do not take proper care of my tattoo. I agree to follow aftercare instructions while my tattoo is healing. I realize that variations in design may exist between any tattoo as selected by me and as ultimately applied to my body. I understand that if I have any skin treatments, laser hair removal, cosmetic surgery or other skin altering procedures, it may result in changes to my tattoo.I acknowledge that a tattoo is a permanent change to my appearance and do not hold my tattooer liable for or of the ability to later change or remove my tattoo. I acknowledge I am over the age of eighteen and that I have truthfully represented to my tattooer that the obtaining of a tattoo is by my choice alone. I fully understand the tattoo artist does not act as a medical professional. I agree to release and discharge my artist from any and all claims, damages, or legal actions arising from or connected to my tattoo and the procedure used in the application of my tattoo. I consent to the application of the tattoo. My tattoo artist and I recognize that I may revoke this consent at any time before or during the tattoo procedure.

By filling out this agreement I grant permission for my photos to be taken on today’s date. I understand that photographs taken of me during this session may be used, wholly or in part, on the internet, in any publication, portfolio, or display, or in any other print or electronic medium as this artist chooses, unless otherwise specified below. I confirm I am 18 years of age or older. I will make no monetary or other claim against this artist for use of the photographs. I understand that my name may or may not be included/credited in any form of publication unless requested otherwise.

Have you experienced any of the following in the last 14 days?: cough, fever, shortness of breath, loss of taste/smell, flu-like symptoms. If you have any symptoms or suspect you may be sick please reach out to reschedule as soon as possible. Deposits will transfer to your new appointment.

Have you been in contact/proximity with a known or suspected COVID patient or anyone experiencing the above symptoms?

Please read the following and sign to acknowledge: No guests will be allowed unless needed and agreed upon prior to the appointment for accessibility reasons, to limit the total number of people in the studio at a time. If you test positive for COVID-19 after your appointment, please alert your artist so that our post-exposure plan may be put into effect.