Tattoo Consent & Waiver Form

Tattoo Artist: *

Business Name: *

Name*

First NameLast Name

Full Name*

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Date of appt.*

Date

Time

Hour Minutes

AM/PM Option

Front of Driver License*

Tap Browse to take photo

Back of Driver License*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Tattoo design and location of Tattoo*

I.e. tattoo of flowers on arm

Any Heart conditions*

YESNO

Are you on any blood thinners*

YESNO

Are you currently Pregnant or breastfeeding (legally must answer truthfully)*

YESNO

Any Bloodborne illnesses/diseases*

YES (REQUIRED BY LAW TO ANSWER CORRECTLY )NO

Select Bloodborne illnesses/diseases (Pick does not apply if it does not apply to you)*

BY LAW YOU MUST DISCLOSE.

(LEAVE BLANK IF NONE) Medical conditions not listed above (NOTE: MUST SPEAK WITH ARTIST IF YOU ARE LISTING ANY CONDITIONS)

I.e. diabetes, epilepsy, Blood Clotting Disorders, Immunosuppressive Diseases or Medications.

Any known allergies?*

YES (Please list below)NO

Allergies:

Age of person getting service:*

(must be 18 or older)

I acknowledge I have been advised of the facts and matters set forth below and I agree as follows:

If the person whom is getting service has 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.
The person getting service is not pregnant or nursing or not under the influence of alcohol or drugs.
I acknowledge it is not possible for the representatives and employees of this location to determine whether I might have an allergic reaction to the pigments or processes used in my tattoo, and I agree to accept all the risk that such a reactionor issue is possible.
I acknowledge that infection is always possible as a result of the obtaining of a tattoo, particularly in the event that I or Gardian of minor do not take proper care of my tattoo. I or Gardian of minor agree to follow aftercare instructions while my tattoo is healing.
I realize that variations in color and design may exist between any tattoo as selected by me and as ultimately applied to my body.
I understand that any skin treatments, laser hair removal, cosmetic surgery or other skin altering procedures, it may result in changes to my services.
I acknowledge that a tattoo is a permanent change to 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. If Minor, I as the gardian consent for service and will not hold PIPER-jade lilable for issues during or after service is completed.
I fully understand the tattoo artist does not act as a medical professional.
I agree to release and discharge any employee at PIPER-jade from any and all claims, damages, or legal actions arising from or connected to my tattoo or Piercing and the procedure used in the application of my tattoo/Piercing.
I consent to the application of the tattoo. My artist and I recognize that I may revoke this consent at any time before or during the service procedure.

Signature

Please note:

By filling your name in below you are electronically signing and agreeing to all terms above

Electronic signature*

First NameLast Name