Hammer N Ink
Consent waiver
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
The date of my appointment is
-
Month
-
Day
Year
Date
I understand that this is a binding contract with Hammer N Ink & I have been given full opportunity to ask any and all questions about my procedure. All of my questions have been answered to my satisfaction. I understand that my procedure may be permanent, and may require surgical procedure for removal. I am aware that removal may cause scarring.
I agree to this statement
I do not have any medical conditions or communicable diseases (including but not limited to diabetes, epilepsy, hemophilia, hepatitis, HIV, AIDS, tuberculosis, COVID19). I do not have a skin condition that may interfere with the proper healing of my procedure (including but not limited to acne, scarring or keloids, eczema, psoriasis, freckles, moles, or sunburn). I am not pregnant or nursing. I have informed an agent of Hammer N Ink and documented below of any exceptions to the above. I am not under the influence of drugs, alcohol, or any narcotic, including but not limited to prescription pharmaceuticals, & over the counter medications. I am aware that being under the influence can have an adverse effect on the procedure. I agree that Hammer N Ink cannot determine if I will have an allergic reaction to any of the products used to complete my procedure. I attest that I have no known allergies, or if I do I have documented them on the back of this form and alerted Hammer N Ink.
I agree to this statement
I am aware of the possibility of infection with my procedure. I understand that when I leave the premises of Hammer N Ink, my procedure is only half complete. It is my responsibility to follow the aftercare procedures recommended by HammerN Ink. Hammer N Ink makes no claim to the success or validity of the recommended aftercare procedures, they are simply guidelines. I agree to not hold Hammer N Ink liable for any necessary touch-up work caused by my own negligence. I agree to leave the premises of Hammer N Ink promptly upon request, for any reason whatsoever, by any employee or agent of Hammer N Ink
I agree to this statement
Today's Date
-
Month
-
Day
Year
Date
Signature
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