Consent Form

After reading, please choose "I Agree" to show that you understand each provision and whether you consent. Feel free to ask any questions.

Who is your tattoo artist:*

Sophia JacksonElatia

What is the location and description of your body art?*

ex. A flower tattoo located on my right arm

Name*

First NameLast Name

In consideration of receiving a tattoo from Wild Vine Ink including its artists, associates, apprentices, agents, or any employees (hereinafter referred to as the “Tattoo Studio” I agree to the following:

I have been fully informed of the inherent risks associated with getting a tattoo. Therefore, I fully understand that these risks, known and unknown, can lead to injury including but not limited to: infection, scarring, difficulties in the detection of melanoma and allergic reactions to tattoo pigment, latex gloves and/or soap. Having been informed of the potential risks associated with getting a tattoo I wish to proceed with the tattoo procedure and freely accept and expressly assume any and all risks that may arise from tattooing.*

I agree

I understand that proper aftercare is essential to prevent infection and promote healing. I have received and understand the instructions provided by the Tattoo Studio and agree to follow them. I acknowledge that failure to do so may lead to complications such as infection. I am aware of the signs and symptoms of infection, including redness, swelling, tenderness, red streaks, fever, or discharge, and I agree to seek professional medical attention should these occur. If any touch-up work to the tattoo is needed due to my own negligence, I agree that the work will be done at my own expense.*

I agree

I understand the restrictions on physical activities such as bathing, recreational water activities, contact with animals etc. and the duration of the restrictions.*

I agree

I understand that the tattoo inks used in this procedure have not been approved by the Federal Food and Drug Administration, and that the potential health consequences of their use are unknown. I also acknowledge that it is not reasonably possible for the Tattoo Studio to determine whether I may have an allergic reaction to the pigments or processes used, and I accept the risk that such a reaction may occur.*

I agree

I acknowledge that I have approved the final artwork and/or stencil for my tattoo, confirmed that all spelling is correct, and ensured the design is placed to my specifications. I understand it is my responsibility to raise any concerns prior to the procedure. I further acknowledge that the Tattoo Studio is not responsible for the meaning or spelling of any symbols or text that I have provided or selected from their design sheets.*

I agree

I understand that receiving a tattoo results in a permanent change to my appearance. I acknowledge that no guarantees have been made regarding the ability to change or remove the tattoo in the future. I also understand that variations in color and design may occur between the selected artwork and the final tattoo, and that over time, the colors and clarity of the tattoo may fade due to sun exposure and the natural dispersion of pigment under the skin.*

I agree

The Tattoo Studio has given me the full opportunity to ask any question about the procedure and application of my tattoo and all of my questions, if any, have been answered to my total satisfaction.*

I agree

I am not under the influence of alcohol or drugs, and I am voluntarily submitting to be tattooed by the Tattoo Studio without duress or coercion.*

I agree

I confirm that I do not have diabetes, hemophilia or heart conditions. I also confirm that I am not taking blood thinning or anticoagulant medications.*

I agree

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

I agree

I do not have skin conditions, diseases or lesions such as but not limited to: acne, scarring (Keloid), eczema, psoriasis, freckles, moles, or sunburn in the area to be tattooed that may interfere with the tattoo.*

I agree

I am not the recipient of an organ or bone marrow transplant or, if I am, I have taken the prescribed preventative regimen of antibiotics that is required by my doctor in advance of any invasive procedure such as tattooing or piercing.*

I agree

I do not have HIV-AIDS, Hepatitis, or any other communicable disease.*

I agree

I do not have a history of epilepsy, seizures, fainting, or narcolepsy.*

I agree

I am not pregnant or nursing. I do not have a mental impairment that may affect my judgment in getting the tattoo.*

I agree

I do not have any other medical or skin condition that may interfere with the procedure, application or healing of the tattoo.*

I agree

I fully understand THE TATTOO ARTIST DOES NOT ACT AS A MEDICAL PROFESSIONAL. Any suggestions made to me are NOT to be construed as or substituted for advice from a medical professional.*

I agree

I release the right to any photographs taken of me and the tattoo and give consent in advance to their reproduction in print or electronic form. (For assurance, if you do not initial this provision, please inform the Tattoo Studio NOT to take any pictures of you and your completed tattoo).*

I agreeI do not agree

I agree that the Tattoo Studio has a NO REFUND policy on tattoos, piercing and/or retail sales and I will not ask for a refund for any reason whatsoever.*

I agree

I WAIVE AND RELEASE to the fullest extent permitted by law any person of the Tattoo Studio from all liability whatsoever, including but not limited to, 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 procedure and application of my tattoo, whether caused by the negligence or fault of either the Tattoo Studio, or otherwise.*

I agree

I agree to reimburse the Tattoo Studio for any attorneys' fees and costs incurred in any legal action I bring against the Tattoo Studio and in which either the Artist of the Tattoo Studio is the prevailing party. I agree that the courts located in the County of Boulder within the State of Colorado shall have jurisdiction and venue over me and shall have exclusive jurisdiction for the purposes of litigating any dispute arising out of or related to this agreement.*

I agree

I acknowledge that I have had the opportunity to read and understand this document, and that I am signing it voluntarily. I understand that this is a legal contract and that by signing it, I am waiving certain rights to recover damages against the Tattoo Studio.*

I agree

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.

I declare that I am of legal age, have provided valid proof of identification, and am competent to sign this Agreement. I have truthfully represented that receiving a tattoo is my personal choice, and I consent to the application of the tattoo and any actions reasonably necessary to perform the procedure. I have read this Agreement in full, I understand its contents, and I agree to be legally bound by it.

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Date of Procedure*

Date

Date of Birth*

Date

Identification*

Emergency Contact*

Signature*

Tattoo Aftercare Instructions

For optimal healing, follow these instructions closely and contact the studio with any questions.

Bandage Removal

● After 1-3 hours, using clean hands, remove the bandage.

● Wash the tattoo gently with unscented mild soap and warm water. Be sure all ointment

has been washed off your skin.

● After washing, blot the tattoo dry with a clean paper towel.

● Let the tattoo air dry for 10-15 minutes before proceeding with further care.

Nighttime Care

● Apply a thin layer of Aquaphor ointment, then rebandage the tattoo with clean plastic

wrap. Repeat this process for the first 2-3 nights, ONLY AT NIGHT. This will prevent the

tattoo from drying out overnight.

● After 2-3 nights, discontinue using the ointment and do not rebandage the tattoo. Use

Curel fragrance-free skin lotion only and leave the tattoo unbandaged.

Daytime Care

● Using clean hands, wash the tattoo gently with unscented mild soap and warm water 2-3

times daily.

● After washing the tattoo, apply a thin layer of ointment for the first 2-3 days. After the first

2-3 days, switch to a small amount of Curel fragrance-free skin lotion.

● Rub the lotion into the tattoo until it has been fully absorbed.

● Use the lotion 3-4 times daily for 2 weeks.

● Your tattoo will start to peel like a sunburn – this is normal! DO NOT pick or scratch your

tattoo.

DO NOT use Neosporin or Bacitracin on the tattoo.

DO NOT pick or scratch the tattoo.

DO NOT submerge the tattoo in the bathtub, ocean, pool, hot tub, etc., while it is healing.

DO NOT touch the tattoo while it is healing other than to clean and moisturize it.

DO NOT expose the tattoo to sunlight or tanning beds while it is healing.

DO avoid strenuous exercise for the first 3 days to allow the tattoo to heal smoothly.

DO keep pets away from the tattoo while it is healing.

DO use sunblock to protect the tattoo after it has healed.

Please see a physician at the first signs and symptoms of infection or allergic reaction, including, but not limited to redness, swelling, tenderness of the procedure site, red streaks going from the procedure site towards the heart, elevated body temperature, or purulent drainage from the procedure site.

If you have any concerns, you can contact Boulder County Public Health at 303-441-1564 or https://bouldercounty.gov/families/disease/body-art-program

Wild Vine Ink

3008 Folsom St, Boulder CO 80304

970-231-1055

Licenced by BCPH: 96-44295-70000

Tattoo Aftercare Instructions with Second Skin

Your tattoo artist has applied a medical-grade, waterproof, breathable tattoo bandage as a “second

skin” to help heal your tattoo. For optimal healing, follow these instructions closely and contact the

studio with any questions.

Days 1-4

● Keep the bandage on for 3-4 days. You may see some plasma/blood/lymph fluid buildup under

the bandage – this is totally normal; leave it alone!

● If the bandage becomes compromised (i.e., leaking, peeling up, or exposing the tattoo), remove

it immediately. Continue to follow the instructions as listed and contact us with any questions.

● The shower is the ideal place to remove the bandage. Warm running water will help loosen the

adhesive and relax the skin. Dry removal may cause discomfort and added trauma to the skin.

● To remove, find an edge and pull it back over itself in the direction of hair growth. Discard the

used bandage.

● With your hands only (no sponges, washcloths, loofahs, etc.), wash the tattoo gently using

unscented mild soap and warm water. Rinse thoroughly to remove all soap residue from your

skin. (Tip: To ensure the soap residue is fully removed, wet a paper towel with rubbing alcohol

and gently rub around the tattoo. DO NOT rub alcohol on the tattoo itself.)

● Blot the tattoo dry with a clean paper towel and let it air dry for 10-15 minutes.

Days 5-20

● Leave the tattoo unbandaged.

● Using clean hands, gently wash the tattoo with unscented mild soap and warm water up to 2

times per day. (Do not overwash your tattoo.)

● After washing, apply a thin layer of fragrance-free skin lotion (Curel, Eucerin, Lubriderm, etc.)

until the lotion is fully absorbed into your skin.

● Use the lotion 3-4 times daily for 2 weeks, or as directed by your artist.

● The tattoo will start to peel like a sunburn – this is normal! DO NOT pick or scratch the tattoo.

DO NOT peel the bandage unless you intend to remove it.

DO NOT use Neosporin or Bacitracin on the tattoo.

DO NOT pick or scratch the tattoo.

DO NOT submerge the tattoo in the bathtub, ocean, pool, hot tub, etc., while it is healing.

DO NOT touch the tattoo while it is healing other than to clean and moisturize it.

DO NOT expose the tattoo to sunlight or tanning beds while it is healing.

DO avoid strenuous exercise for the first 3 days to allow the tattoo to heal smoothly.

DO keep pets away from the tattoo while it is healing.

DO use sunblock to protect the tattoo after it has healed.

Please see a physician at the first signs and symptoms of infection or allergic reaction, including, but not limited to redness, swelling, tenderness of the procedure site, red streaks going from the procedure site towards the heart, elevated body temperature, or purulent drainage from the procedure site.

If you have any concerns, you can contact Boulder County Public Health at 303-441-1564 or https://bouldercounty.gov/families/disease/body-art-program

Wild Vine Ink

3008 Folsom St, Boulder CO 80304

970-231-1055

Licenced by BCPH: 96-44295-70000

Tattoo Consent Form