Old West Tattoo Consent Form

Full Name*

First NameLast Name

Age*

Date of Birth*

Date

Phone Number*

Format: (000) 000-0000.

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name of the artist doing your tattoo*

I have trustfully represented to my tattooer that I am at least 18 years old. I acknowledge that the obtaining of a tattoo is by my choice alone. I consent to the application of the tattoo and to any actions or conduct of the tattooer, contractors, or employees of Old West Tattoo that is reasonably necessary to perform the tattoo procedure.*

Acknowledge

I acknowledge I have eaten within the last 4 hours, that I am not under the influence of drugs or alcohol, and I have not taken any form of aspirin, ibuprofen, or anticoagulants within the last 24 hours.*

Acknowledge

I am not pregnant or nursing. I do not have epilepsy or hemophilia. I do not suffer from any heart conditions or take medication which thins the blood. I am not currently taking any antibiotics or Accutane. I have informed my tattooer of any conditions that compromise my immune system annd any conditions such as diabetes that might hamper healing of the tattoo.*

Acknowledge

If I suffer from hepatitis or any other communicable disease, I have informed the tattoo artist and I have been advised of any procedures necessary to promote the satisfactory healing of my tattoo. Artists will never refuse service based on any communicable disease.*

Acknowledge

I do not suffer from any medical or skin conditions such as, but not limited to; keloid or hypertrophic scarring, psoriasis at the site of the tattoo, sunburn, or any open wounds or lesions at the site of the tattoo*

Acknowledge

I acknowledge that I do not suffer from hemophilia, epilepsy, narcolepsy, dizziness, fainting, or any form of seizure causing condition that could interfere with the procedure.*

Acknowledge

I have advised the tattooer of any allergies to metals, soaps, and medications. I acknowledge it is not reasonably possible for the tattooer to determine whether I might have any allergic reactions to the tattoo, inks, or process involved in getting a tattoo and I further acknowledge that reaction to the pigments is possible, even after the tattoo has healed.*

Acknowledge

I have informed my tattooer of any allergies to latex or other adhesives. Tattooers do sometimes use latex gloves for procedures. Nitrile gloves can be used if requested.*

Acknowledge

I acknowledge that there may be side effects from this procedure, including swelling, and or bruising. Infection and or irritation is always possible as a result of obtaining a tattoo. I will receive aftercare instructions upon completion of my tattoo and I will follow all instructions while my tattoo is healing. If I have any issues or concerns with the tattoo I will contact my tattoo artist.*

Acknowledge

To my knowledge I do not have any physical, mental, or medical impairments or disabilities which might affect my well being as a direct or indirect result of my decision to have a tattoo*

Acknowledge

I understand that every care has been taken to ensure that this procedure has been carried out in a hygienic manner, and the aftercare of the tattoo is my sole responsibility*

Acknowledge

I acknowledge that I have seen the tattoo design and have agreed to it with the tattooer. If later I decide that I want something else or to change the design that will be done at the standard rate if they are possible.*

Acknowledge

I give consent to allow Old West Tattoo and its team members the use of photography and videography which may include myself & or parts of my body for marketing and social media purposes*

Acknowledge

Skin conditions (e.g. Rashes, eczema, infection, psoriasis, freckles, etc.)

If yes, please identify the condition.

Release*

I consent to allow one of the team members at Old West Tattoo/Sovereign Rescources LLC to provide me with a tattoo. In consideration of doing so, I hereby release Old West Tattoo, Sovereign Resources LLC, and or Sovereign Asset Management, its independent contracted artists, affiliates, and or agents from all manner of liabilities, claims, actions and/or demands, in law or in equity, which I or mey heirs have or might have now or hereafter by reason of complying with my request to be tattooed. I fully understand that any independent contractor, employee, artist, or agent of Old West Tattoo, Sovereign Resources LLC, and or Sovereign Asset Managment, when performing tattooing, does not fact in the capacity of a medical professional. The suggestions made by an artist or agent of Old West Tattoo, Sovereign Resources LLC, and or Sovereign Asset Management, are just suggestions that are not to be misconstrued or as substituted for advice from a medical professional. I understand I will be tattooed using appropriate instruments, procedures, and techniques. To ensure proper healing of my tattoo, I agree to follow the aftercare procedures outlined in the tattoo aftercare instructions, until the healing is complete. I understand that this type of tattoo usually takes one to two weeks, or longer to heal. I willing submit to these procedures, with a full understanding of possible complications such as, but not limited to, infection, allergic reaction, and/or rejection of inks and or pigments. I have received a copy of the tattoo aftercare, which I have read and fully understand and hereby assume full responsibility for aftercare and cleanliness. I understand that by having this tattoo procedure performed I am making a permanent change to my body and no claims have been made regarding the ability to undo the changes made. I agree to wave and release and forever discharge and hold harmless to the fullest extent of the law, Old West Tattoo, Sovereign Resources LLC, Sovereign Asset Management, ownership , artists, independent contractors, our estate, heirs, executors, or assigns may have for personal injury or otherwise, including any direct and or consequential damages, which result or arise, whether cased by the negligence or fault of either the tattoo artist, tattoo shop, or otherwise, and all owners, contractors, employees from any and all claims, damages or legal actions arising from or connected in any way with my tattoo or the procedure and conduct used in my tattoo.I consent to any actions or conduct of the representatives, contractors, and or employees of the Old West Tattoo necessary to perform the aforementioned procedure.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 tattooI acknowledge that Old West Tattoo, Sovereign Resources LLC, and or Sovereign Asset Management LLC, any of its affiliates, contractors, artists, nor employees offer refunds

Aftercare*

I understand that any medical or skin condition such as but not limited to: acne, scarring, eczema, psoriasis, freckles, moles, rash, and or sunburn in the area to be tattooed that may interfere with your tattoo and or the healing process of said tattooI understand that I might get an infection if I don't follow the instructions given to me in regards of taking care of my tattooI understand that I need to take care of the tattoo by following the instructions given to me by the staff of Old West TattooI understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my tattoo.I acknowledge that both written and verbal instructions regarding risk, outcome, and aftercare were given to me

Touch Ups*

I understand that each individual artist at Old West Tattoo are responsible for touch ups of his or her work within a 6 month period from the original date of services. If touch ups are needed I must contact my tattooer within ninety (90) days of the tattoo being done. The specific artist that did your tattoo will be responsible for doing your touch up. Tattoos that require touch ups that are not due to any client error are free of charge. Touch ups due to client error in following aftercare instructions or for any reason outside of the control of the tattoo artist are charged at the normal tattoo rate.I agree that touch up work needed due to my own negligence will be at my own expense.

*

I confirm that the information I provided in this document is accurate and true.

How did you hear about us?

Signed Date*

Date

Client Signature*

Upload your photo ID below. Please present your photo ID to an Old West staff member before uploading.*

Consent to Tattoo Procedure

Client Information

Acknowledgment and Waiver