AESTHETIC INK CONSENT FORM

CONSENT TO APPLICATION OF TATTOO AND RELEASE WAIVER OF ALL CLAIMS

I acknowledge by signing this consent form that I have been given the full opportunity to ask any and all questions I might have about obtaining a tattoo from Aesthetic Ink and that all of my questions have been answered to my full and total satisfaction. I specifically acknowledge that I have been advised of the facts and matters set forth below as follows:
Client Information
Name*

First NameLast Name
Age*
Birth Date*

MonthDayYear
Date
Phone Number*
Format: (000) 000-0000.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pre-Procedure Questionnaire
Are you under the influence of drugs or alcohol?*

YesNo
Do you have any acne, freckles, moles, or sunburn in the area that might affect the tattoo?*

YesNo
FEMALE ONLY: Are you pregnant or nursing?

YesNo
Do you have a communicable disease?*

YesNo
Do you have any skin conditions?*

YesNo
Skin conditions (e.g. Rashes, eczema, infection, psoriasis, freckles, etc.) or communicable diseases (e.g. HIV/AIDS, Hepatitis, TB)
If yes, please identify the condition.
Please tell about your medical history (e.g. Diabetes, Cardiovascular Disease, Epilepsy, Blood-related disease etc.)
If yes, please identify the condition.
Acknowledgment and Waiver
*

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

I acknowledge that I have truthfully represented to the employees and representatives of Aesthetic Ink that I am over (18) years old or, if under 18, I have parental consent.
*

I acknowledge that it is not reasonably possible for the employees of Aesthetic Ink to determine whether I might have an allergic reaction to the dyes, pigments or processes used in my tattoo, and I agree to accept the risk that such a reaction is possible.
*

I agree to allow my tattoo to be photographed and be used for Aesthetic Ink’s portfolio and/or social media accounts.
*

I acknowledge that the deposit and procedure are non-refundable.
*

I acknowledge receipt of written and/or verbal aftercare instructions for my tattoo, including the use of second-skin bandaging. I understand that I must leave the initial second-skin bandage on for 24 hours, then wash the tattoo with antibacterial soap, apply a new piece of second skin, and leave it in place for up to six days. I recognize the absolute necessity of following these instructions for proper healing.
*

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 variations in color and design may exist between any tattoo as selected by me and as ultimately applies to my body.
*

I acknowledge that my tattoo may cause scarring.
*

I acknowledge that there is a chance I might feel lightheaded, dizzy during or after being tattooed. I agree to immediately notify the practitioner in the event I feel lightheaded, dizzy and/or faint before, during or after the procedure.
*

I agree to follow all instructions concerning the care of my tattoo, and that any touch-ups needed because of my own negligence will be done at my own expense.
*

I acknowledge that all tattoos on hands, feet and neck are not guaranteed. If a touchup is needed I may be charged.
*

I acknowledge that it is my responsibility to ensure that for desired name(s), word(s), or phrase(s) that the SPELLING, FONT, AND FONT SIZE are correct and accurate.
*

I acknowledge that it is my responsibility to ensure that for placement of the tattoo(s) is correct and exactly where I desire it to be. The tattoo artist will place the stencil of the tattoo and ask you if you are satisfied. It is my responsibility to make sure it is where I want it.
*

I acknowledge that in the case any legal action may arise, I am fully responsible for the legal fees of both parties.
*

I agree to release and forever discharge and hold harmless Aesthetic Ink and its agents, employees, officers and shareholders from any and all claims, damages or legal actions arising from or connected in any way with my tattoo or procedures and the conduct used to apply my tattoo.
*

I confirm that the information I provided in this document is accurate and true.
Client Signature*
Signed Date*

MonthDayYear
Date
Should be Empty:

CONSENT TO APPLICATION OF TATTOO AND RELEASE WAIVER OF ALL CLAIMS

Client Information

Pre-Procedure Questionnaire

Acknowledgment and Waiver