Element Tattoo Studio — Client Record & Release Form

Element Tattoo Studio — Client Record & Release Form

4741 Fredericksburg Road, San Antonio, TX 78229 | (210) 979-9877 | contact@elementtattoo.com | elementtattoo.com
Client Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Acknowledgements

You are hereby notified of any and all requirements &/or risks associated with receiving a tattoo. Please read & initial. Enter your initials in each box below.
I certify that I am at least 18 years of age.

Write your initials using a stylus, finger, or mouse.
I certify that I am not under the influence of drugs or alcohol.

Write your initials using a stylus, finger, or mouse.
I certify that I am of sound mind.

Write your initials using a stylus, finger, or mouse.
I understand that a tattoo is painful and permanent.

Write your initials using a stylus, finger, or mouse.
I understand that aftercare of my tattoo is my responsibility and that neither Element Tattoo nor its staff are responsible nor liable for infection or discoloration due to neglect.

Write your initials using a stylus, finger, or mouse.
I understand there is always a possibility of infection or allergic reaction to pigments and/or materials used in application.

Write your initials using a stylus, finger, or mouse.
I certify that I am not pregnant. Element Tattoo does not tattoo pregnant nor breastfeeding women due to the health concerns for mother and child.

Write your initials using a stylus, finger, or mouse.
I agree to inform Element Tattoo of the risk of epilepsy.

Write your initials using a stylus, finger, or mouse.
I agree to inform Element Tattoo and its staff of any blood borne pathogens and diseases that I may have to ensure that proper precautions are taken for containment and the health of tattooer/client. This includes HIV, AIDS, and all forms of hepatitis.

Write your initials using a stylus, finger, or mouse.
I understand that receiving a tattoo may cause swelling, bruising and discoloration of tattoo and surrounding areas.

Write your initials using a stylus, finger, or mouse.
I consent to allowing the use of photographic images and video of my tattoo for artist and marketing purposes.

Write your initials using a stylus, finger, or mouse.
I have read and understand all of the above requirements prior to receiving tattoo services.

Write your initials using a stylus, finger, or mouse.
Client Information
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Driver’s License / Photo ID Picture (optional)

On your phone or tablet, tap here and choose Take Photo or Camera, or select an existing picture.
Cancelof
I have received a copy of applicable written care instructions & I have read and understand such written care instructions.
Client Signature
Staff Use Only

TO BE COMPLETED BY ELEMENT TATTOO STUDIO STAFF / TATTOO ARTIST
Tattoo Artist
Client Age
Type of Valid Identification
Location of Tattoo
Subject
Price (USD)
Notes
An Artist may not tattoo a person younger than 18 years of age without meeting the requirements of 25 Texas Administrative Code, §229.406(d), whose parent or guardian determines it to be in the best interest of the minor child to cover an existing tattoo.
Should be Empty:

Element Tattoo Studio — Client Record & Release Form

Acknowledgements

Client Information

Staff Use Only