Piercing Consent Form

Date*

Date

Legal Name*

First NameLast Name

Email*

example@example.com

Date of Birth*

Date

Age*

Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Driver's License Number*

Driver's License Photo*

Is the client a minor (under 18)?*

YesNo

Parent or Guardian Legal Name

First NameLast Name

Parent or Guardian Driver's License Number

Parent or Guardian Driver's License Photo

Tattoo Artist*

Tattoo Artist

Artist Email

example@example.com

In consideration of receiving a tattoo from at Mountain Coast Ink, together with its employees, apprentices and agents, Mountain Coast Ink, I agree to the following:

That I (your legal name) blanks*have been fully informed of the inherent risks, associated with getting a tattoo. I fully understand that these risks, known and unknown, can lead to injury, including but not limited to infection or scarring. Having been informed of the potential risks associated with getting a tattoo, I still wish to proceed with the tattoo application and I freely accept and expressly assume any and all risks that may arise from a tattoo.

Initials*

TO WAIVE AND RELEASE to the fullest extent permitted by law Type a label and Mountain Coast Ink from all liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise from the application of my tattoo, whether caused by the negligence or fault of either Type a label or the Mountain Coast Ink, or otherwise.

Initials*

That both Mountain Coast Ink and Type a label have given me the full opportunity to ask any and all questions about the application of my tattoo and all of my questions have been answered to my total satisfaction.

Initials*

Type a label and Mountain Coast Ink have given me instructions on the care of my tattoo while it’s healing, and I understand them and will follow them. I acknowledge that it is possible that the tattoo can become infected, particularly if I do not follow the instructions given to me.

Initials*

I am not under the influence of alcohol or drugs, and I am voluntarily submitting to a tattoo by Type a label without duress or coercion.

Initials*

Neither Type a labelnor Mountain Coast Ink is response for the meaning or spelling of the symbol or text that has been provided by the customer.

Initials*

I do not have diabetes, epilepsy, hemophilia, a heart condition, nor do I take blood thinning medication. I am not neurologically or immune compromised. I do not have any other medical or skin condition that may interfere with the application or healing of the tattoo. I am not the recipient of an organ or bone marrow transplant or, if I am, I have taken the prescribed preventive regimen of anti-biotics that is required by my doctor in advance of any invasive procedure such as tattooing and piercing. I am not pregnant or nursing. I do not have a mental impairment that may affect my judgment in getting the tattoo.

Initials*

I do not have allergies or advers reactions to latex pigments, dyes, disinfectants, soaps or metals.

Initials*

I am not pregnant or nursing.

Initials*

Variations in color and design may exist between the tattoo art I have selected and the actual tattoo when it is applied to my body. I also understand that over time, the colors and the clarity of my tattoo will fade due to unprotected exposure to the sun and the natually occurring dispersion of pigment under the skin.

Initials*

A tattoo is a permanent change to my appearance and can only be removed by laser or surgical means, which can be disfiguring and/or costly and which in all likelihood will not result in the restoration of my skin to its exact appearance before being tattooed.

Initials*

I release all rights to any photographs taken of me and the tattoo and give consent in advance to their reproduction in print or electronic form. (If you do not initial this provision please advise and remind Type a label and Mountain Coast Ink, NOT to take any pictures of you and your completed tattoo).

Initials*

I agree to reimburse Type a labeland Mountain Coast Ink for any attorney fees and costs incurred in any legal action I bring against either Type a label or Mountain Coast Ink and in which either Type a label or Mountain Coast Ink is the prevailing party. I agree that the that the courts of COLORADO in JEFFERSON COUNTY shall have personal jurisdiction and venue over me and shall have exclusive jurisdiction for the purpose of litigating any dispute arising out of or related to this agreement.

Initials*

I acknowledge that I have been given adequate opportunity to read and understand this document, that it was not presented to me at the last minute, and I understand that I am signing a legal contract waiving certain rights to recover Type a label and Mountain Coast Ink.

Initials*

If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.

Initials*

I hereby declare that I am of legal age (and have provided valid proof of age) and am competent to sign this Agreement or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or legal guardian is in complete understanding and concurrence with this agreement.

Initials*

Upload a picture of your valid photo ID

Client Legal Name

First NameLast Name

CLIENT SIGNATURE*

In Case of Emergency Contact Colorado State Dept. of Health #: 303-692-2000

Mountain Coast Ink Tattoo Client Consent Form

Please Initial Below Each Provision - Thank You

CLIENT SIGNATURE: