Atlanta Ink Consent Form

CONSENT FORM

I Client's Name* , hereby give consent to * of Atlanta Ink to perform a * , and in consideration of doing so, I hereby release Atlanta Ink and the artist above from all manner liabilities, claim, action, and demand in law or in equity which I or my heirs might now or hereafter by reason of complying with my request of a tattoo or body piercing.

I fully understand that any artist of Atlanta Ink, when performing a tattoo or body piercing, does not act in the capacity as a medical professional. The suggestions made by any artist of Atlanta Ink are just suggestions. They are not to be construed as or substituted for advice from a medical professional.

I understand that the tattoo or piercing will be performed using appropriate techniques, instruments, and pigment. I also understand that infections can occur due to lack of proper hygiene and or pigment sensitivities. To ensure proper healing of my tattoo or body piercing, I agree to follow the written instructions on www.atlantainksouth.com/aftercare and verbal aftercare instructions that will be provided, until healing is complete. I understand that a tattoo may take several weeks to heal properly. I also understand that a body piercing may take several months to fully heal.

I understand that I am making a permanent change to my body, and no claims about the possible of reversing these changes have been made or implied by Atlanta Ink or any of its tattoo artist or piercers. By signing this consent form I fully consent to the alteration of my body by Atlanta Ink artist.

Has a physician told you that you have hepatitis?*

YesNo

Are you HIV positive ?*

YesNo

Have you been jaundice (yellowing of skin or eyes) in the previous 10 days?*

YesNo

Do you have high blood pressure?*

YesNo

Are you prone to fainting?*

YesNo

Do you have diabetes?*

YesNo

Do you take blood thinner medicine?*

YesNo

Do you have difficulty stopping bleeding? *

YesNo

Do you have heart related problem?*

YesNo

Are you pregnant?*

YesNo

Within the last 14 days have you tested positive for Covid-19?*

YesNo

If yes, have you been cleared by a physician to be outside of the infectious period?*

YesNoI have not tested positive for Covid in the last 14 days.

Do you have any known allergies? (Ex: Nickel, Soy, Peanuts, etc..)*

YesNo

If so, please list them*

Have you consumed any alcoholic beverages within the last 8 hours?*

YesNo

Have you consumed any food within the last 2 hours?*

YesNo

Have you consumed any anticoagulants (aspirin, ibuprofen, Etc.) in the last 24 hours?*

YesNo

Do you have any other conditions that might affect the healing of this tattoo/body piercing?*

YesNo

Name*

First NameLast Name

Telephone number *

Date of Birth *

MonthDayYear

Email*

example@example.com

What's your Instagram handle? (Write "None" if you do not have one)*

Area of Tattoo or Piercing? (IE; Arm, Leg, Nose, Ear, ..Etc)*

How did you hear about us (Atlanta Ink)?*

How did you hear about your Artist?*

Did you pay a deposit?*

How much?*

$

Where did you pay your deposit?*

Please upload a photo of Valid Government ID (State ID, Driver's License, Military ID, or Passport)*

Clients Signature *

Should you have need to contact the Georgia Health Department please contact:

200 Peidmont Avenue SE, Atlanta GA 30334

404-657-2700

Office Use Only

Artist Name & Body Art License #

Full NameBody Art License number

Artist Signature

Please answer the following questions by circling “Yes” or “No”.

CLIENT DETAIL