Tattoo Consent Form Luna Moon Ink

Please initial in the boxes provided after reading to show that you understand each provision. Feel free to ask any questions regarding this wavier.

In consideration of receiving a tattoo from Luna Moon Ink including its artists,
associates, apprentices, agents, or any employees (Hereinafter referred to as
“Luna Moon Ink” I agree to the following:

I, blanks (Print Name) have been fully
informed of the 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, scarring, difficulties in the detection of melanoma and allergic reactions to tattoo pigment, aftercare products and/or soap. Having been informed of the potential risks associated with getting a tattoo I wish to proceed with the tattoo procedure and application and freely accept and expressly assume all risks that may arise from tattooing. Signature

I WAIVE AND RELEASE to the fullest extent permitted by law any person of Luna Moon Ink 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. Initials

Luna Moon Ink has given me the full opportunity to ask any questions about the procedure and application of my tattoo and all my questions have been answered to my satisfaction. Initials

Luna Moon Ink has given me instructions on the care of my tattoo while it's healing. I understand 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. 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. Initials

I am not under the influence of alcohol or drugs, and I am voluntarily submitting to be tattooed by Luna Moon Ink without duress or coercion. Initials

I do not suffer from diabetes, epilepsy, hemophilia, heart condition(s), nor do I take blood thinning medication. I do not have any other medical or skin condition that may interfere with the procedure, 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 preventative regimen of antibiotics that is required by my doctor in advance of any invasive procedure such as tattooing or piercing. I am not pregnant or nursing. I do not have a mental impairment that may affect my judgement in getting the tattoo. Initials

I am not allergic to lidocaine, and consent to the use of a lidocaine solution as a numbing agent during the application of my tattoo. If you are allergic to lidocaine or do not want it to be used, please inform your tattoo artist prior to beginning the procedure. Initials

Luna Moon Ink is not responsible for the meaning or spelling of the symbol or text that I have provide to them or chosen from the flash (design) sheets. 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 naturally 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 the right to any photographs or videos taken of me and the tattoo and give consent in advance to their reproduction in print or electronic form. I understand that Luna Moon Ink owns the photographs and videos of me and my tattoo, and Luna Moon Ink may use them however they would like. I understand that I do not own any royalties to the photographs or videos. Initials

I agree that Luna Moon Ink has a NO REFUND policy on tattoos and/or retail sales and I will not ask for a refund for any reason whatsoever. Initials

I agree to reimburse Luna Moon Ink for any attorneys' fees and costs incurred in any legal action I bring against Luna Moon Ink and in which the Artist of Luna Moon Ink is the prevailing party. I agree that the courts located in the County of Santa Clara within the State of California 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. 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 grasp that I am signing a legal contract waiving certain rights to recover damages against Luna Moon Ink. 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
identification) and am competent to sign this Agreement.

I HAVE READ THE AGREEMENT, I UNDERSTAND IT, AND I AGREE TO BE BOUND
BY IT.

**PLEASE ASK YOUR ARTIST ABOUT THE PRICE OF YOUR TATTOO BEFORE
BEGINNING THE PROCEDURE - it is your responsibility to confirm the price of the
tattoo, and we assume no responsibility for any misunderstanding in this regard.

Name

First NameLast Name

Signature

Date of Birth

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Driver's License or ID #

Upload a photo of your driver's license (front)