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American Vintage
632 E Katella Ave. Orange, CA 92867 Consent to Tattoo, Release, and Waiver of All Claims.
15
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1
Who is applying your tattoo?
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Choose an Artist
Chris de Armas
Spider
Neal Monier
Jason
Braeden Page
Pokey
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2
Questionnaire
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Please check all that apply
I acknowledge that obtaining this tattoo is my choice alone and the needles and inks will go into my skin and will result in a permanent change to my appearance, and that no representations have been made to me as to the ability to later restore the skin involved in the tattoo to its pre-tattoo condition, and it is very costly to be removed.
I am not pregnant or nursing. I do not have any history of herpes infection at the proposed procedure site. I do not have epilepsy, diabetes, and allergic reaction to latex or antibiotics, hemophilia or other bleeding disorder. I do not have cardiac valve disease or suffer from any heart conditions or take medications, which thins my blood.
If I suffer from hepatitis, or other risk factors for bloodborne pathogen exposure, or any other communicable disease, I have informed the Tattooer of the fact and have been advised of any medications and/or procedure necessary to promote the satisfactory healing of my tattoo. Please advise the Tattooer if you are an organ recipient.
I do not suffer from any medical or skin condition(s) such as, but not limited to: keloid or hypertrophic scarring, psoriasis at the site of the tattoo, or any open wounds or lesions at the site of the tattoo. I understand that having a tattoo may make it more difficult to identify skin conditions, such as cancer, and I still wish to be tattooed.
I do not have a history of medication use and am not currently using medication, including being prescribed antibiotics prior to dental or surgical procedures.
I have advised the Tattooer of any allergies to latex gloves, soaps, or medications. I acknowledge it is not reasonably possible for the Tattooer to determine whether I might have allergic reaction to the tattoo ink or with the process involved in the tattoo and further acknowledge that such reaction is possible.
I have truthfully represented to the Tattooer that I am 18 years of age or older. I am not under the influence of any drugs or alcohol. To my knowledge, I do not have any physical, mental, or medical impairment or disability that might affect my well being as a direct or indirect result of my decision to have a tattoo at this time.
I acknowledge infection is always possible as a result of obtaining a tattoo, and I agree to follow all suggested instructions concerning the care of my tattoo while it is healing.
I acknowledge that a tattoo will itch, scab, and flake during the healing process, and requires special care for proper healing. Aftercare instructions have been provided, and I agree to follow the instructions.
I acknowledge and give consent to American Vintage Tattoo and a third party to use images of my tattoo(s) for marketing and, or publishing purposes in various media such as the internet, magazine, printed, and or television, etc.
I understand I will be tattooed using appropriate instruments and sterilization techniques. Therefore, I requested the Tattooer to tattoo me. I understand that the tattoo usually takes 2-6 weeks or longer to heal. I agree to release and forever discharge, and hold harmless, the Tattooer, all employees, contractors, and the management of American Vintage Tattoo from any and all claims of negligence, damages, or legal actions arising from or connected in any way with my tattoo, the procedure, and conduct used in my tattoo and assume all responsibility for the decision(s) made consenting to this permanent procedure. The Tattooer and American Vintage Tattoo are not responsible for the meaning of any symbol, and cannot verify the spelling of tattoos in foreign languages.
I understand that inks, dyes, and pigments have not been approved by the federal Food and Drug Administration and that the health consequences of using these products are unknown.
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3
List any medications you are on and/or allergies you have below
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List allergies here
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4
Have you eaten in the last couple of hours?
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YES
NO
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5
Name
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First Name
Last Name
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6
Date of Birth
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Date
Month
Day
Year
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7
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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eSwatini
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Other
Please Select
Please Select
United States
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
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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8
Email
(Optional)
example@example.com
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9
Phone Number
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Area Code
Phone Number
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10
Today's Date
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11
Take Photo of I.D.
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12
Scan I.D.
Top right of the back of the I.D.
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13
Signature
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Please sign your name for consent
Clear
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14
Take Photo of Lot #s and Expiration Dates
(TUBES)
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15
Take Photo of Lot #s and Expiration Dates
(NEEDLES)
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