BOSTON TATTOO COMPANY TATTOO RELEASE FORM

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Today's Date* This field is required.
Date
Month
Day
Year
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Are you 18 years old or older?* This field is required.
YESNO
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Full Name:* This field is required.
Legal First Name
Legal Last Name
Preferred Name
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What is your gender?
Male
Unknown/Decline to Answer
Female
X
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Phone Number* This field is required.
Area Code
Phone Number
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Birth DatePlease Select Your Birth Date
Date
Year
Month
Day
8
Is Your Visit Today An Appointment?* This field is required.
Walk-In
Appointment
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Which Of Our Locations Are You Visiting Today?* This field is required.
Somerville (Davis Square)
Medford (Fellsway)
North Conway
Boston (Newbury Street)
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How Did You Hear About Us?* This field is required.
Friend/Family
Social Media
Drive By
Web Search
Other
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Would you like us to call you on your mobile?* This field is required.
YES
NO
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E-mail* This field is required.
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In the last six months have you had any Tattooing or Piercing?* This field is required.
Yes
No
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If selected "Yes" in previous question, please provide an explanation of your recent Tattooing or Piercing.
Please describe what work was performed
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Do You Feel Well Today?* This field is required.
YES
NO
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I do not suffer from any of the following conditions: Diabetes, epilepsy, hemophilia, a heart condition, nor do I take blood-thinning medication. I do not have a history of diabetes; hemophilia (bleeding); history of skin diseases, skin lesions, or skin sensitivities to soaps, disinfectants etc; history of allergies or adverse reactions to pigments, dyes or other sensitivities; history of epilepsy, seizures, fainting or narcolepsy; a history if use of medications such as anticoagulants which thin blood and interfere with clotting; or any other conditions such as hepatitis or HIV. I do not have any other medical conditions or skin conditions that may interfere with the application or healing of the tattoo. I am not the recipient of an organ or bone marrow transplant, or if, I am, have taken the prescribed preventative regimen of antibiotics that is required by my physician in advance of this tattoo. I am not pregnant or nursing. I do not have a mental impairment that may affect my judgement in getting the tattoo.* This field is required.
I DO NOT suffer from a condition
I DO suffer from a condition
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Have you had any of the following symptoms in the past three days that are not explain by allergies or non-infectious cause: Cough Shortness of breath or difficulty breathing, Fever or chills, Muscle or body aches, Sore throat, Headache, Nausea or vomiting, Diarrhea, Runny or stuffy nose, Fatigue, Recent loss of taste or smell?* This field is required.
I have had one or more of these symptoms
I have NOT had one or more of these symptoms
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Have you been in close contact with anyone with COVID-19 in the past 14 days?* This field is required.
YESNO
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Have you been directed to quarantine or isolate in the last 14 days?* This field is required.
YESNO
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PLEASE ACKNOWLEDGE:* This field is required.
IF YOU HAVE ANSWERED YES to any of the following questions you may not be able to enter this building for the safety of the staff and other patrons.
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* This field is required.
I AM NOT under the influence of alcohol or drugs, and I am voluntarily submitting to be tattooed by the Artist and The Boston Tattoo Company without duress or coercion.
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* This field is required.
I UNDERSTAND that 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 naturally occurring dispersion of pigment under the skin.
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* This field is required.
I UNDERSTAND that 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.
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* This field is required.
THE ARTIST AND THE BOSTON TATTOO COMPANY have given me instructions on the care of my tattoo while it's healing; and I understand them and will follow them explicitly. 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 touchup work to the tattoo is needed due to my own negligence, I agree that the work will be done at my own expense.
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Please Describe The Tattoo The Best You Can* This field is required.(Ex. "Eagle With Lettering")
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Where Will The Tattoo Be Located On Your Body?* This field is required.
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Which Artist Will You Be Working With Today?* This field is required.
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* This field is required.
I AGREE that I have been fully informed of the inherent 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 detecting melanoma, allergic reactions to tattoo pigment, latex gloves, and/or soap. Having been informed of the potential risks associated with getting a tattoo, I still wish to proceed with the tattoo application and I freely accept and expressly assume any and all risks that may arise from tattooing.
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* This field is required.
I ACKNOWLEDGE that both the Artist and The Boston Tattoo Company have given me the full opportunity to ask any and all questions about the application of my tattoo and all of my questions have been answered to my total satisfaction.
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* This field is required.
I AGREE to reimburse each of the Artists and The Boston Tattoo Company for any attorneys' fees and costs incurred in any legal action I bring against either the Artist or The Boston Tattoo Company and in which either the Artist or The Boston Tattoo Company is the prevailing party. I agree that the courts of Massachusetts shall have personal jurisdiction and venue over me and shall have exclusive jurisdiction for the purpose of litigating any dispute arising out of or related to this agreement.
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* This field is required.
TO WAIVE AND RELEASE to the fullest extent permitted by Massachusetts Law each of the artists, owners, corporate officers, employees, apprentices, assignees, independent contractors and successors, and The Boston Tattoo Company, d/b/a Type A Design, LLC, from any and all liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors or assignees may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise from the application of my tattoo, whether caused by the negligence or fault of either the artist or The Boston Tattoo Company.
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Please take a snapshot of your unexpired photo ID (excluding CAC & Military ID) by clicking the button below:* This field is required.Please Make Sure The ID Is Fit Within The Screen, you may need to scroll down to see the shutter button - Thank You!
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I have reviewed, understood, and agreed to the policies and requirements of The Boston Tattoo Company, and hereby give my consent to The Boston Tattoo Company to perform the tattoo work on my person. I have received and agree to follow all aftercare instructions.* This field is required.
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