Tattoo & Body Piercing Procedure Waiver
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
The date of my appointment is
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
I understand that this is a binding contract with Charlene Melissa & 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 the agent of Tattoo Studio 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 Tattoo Studio 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 the agent of Charlene Melissa.
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 Charlene Melissa, my procedure is only half complete. It is my responsibility to follow the aftercare procedures recommended by Charlene Melissa. Charlene Melissa makes no claim to the success or validity of the recommended aftercare procedures, they are simply guidelines. I agree to not hold Charlene Melissa liable for any necessary touch-up work cause by my own negligence. I understand that skin color will have an effect on the final result of my tattoo. I agree to leave the premises of Charlene Melissa or any other location where Charlene Melissa is engaged in business promptly upon request, for any reason whatsoever, by any employee or agent of Charlene Melissa.
I agree to this statement
Today's Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Submit
Should be Empty: