Tattoo & Body Piercing Procedure Waiver

Name

First NameLast Name

Email address

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

The date of my appointment is

Date

I understand that this is a binding contract with the piercer & 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 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 piercer 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 the piercer 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 below under other and told my piercer.

Other

I am aware of the possibility of infection with my procedure. I understand that when I leave the premises of the studio,my procedure is only half complete. It is my responsibility to follow the aftercare procedures recommended by the piercer. Brittany Garcia makes no claim to the success or validity of the recommended aftercare procedures, they are simply guidelines. I agree to leave the premises of the studio or any other location where Brittany Garcia is engaged in business promptly upon request, for any reason whatsoever, by any employee or agent of the studio.

I am at least 18 years old.

I am currently pregnant.

I have a history of herpes infection at the proposed procedure site

I have diabetes

I have allergic reactions to latex or antibiotics.

I have hemophilia, a bleeding disorder, or cardiac valve disease

I have a history of medication use and I am not currently using medication, including prescribed antibiotics prior to dental or surgical procedures.

I have other risk factors for bloodborne pathogen exposure.

Acknowledgement

• I certify that I am at least 18 years of age.

• Tattoo inks, dyes, and pigments have not been approved by FDA and the health consequences of using these products are unknown.

• There may be a certain amount of pain, minor bleeding, bruising, redness, or other discoloration, and swelling at the procedure site area during and after the body art procedure.

• There is a possibility of an allergic reaction or an infection.

• Body art is a permanent change to my appearance and removal may not result in the restoration of the skin to its exact original condition.

• Written instructions advising on the proper care of the procedure site, restrictions on physical activities, signs and symptoms of infection, and signs and symptoms of when to seek medical care were provided to me.

Today's Date

Date

Signature

Please provide a photo of your government issued ID. (example; Drivers license , Passport) Minors must submit photo of the legal guardians ID that will present with them at the time of the procedure.