CONSENT TO TATTOO PROCEDURE
NORTH STREET TATTOO
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Artist
*
Jimmy Snaz
Joe Mallard
Kyle MacKenzie
Terry
• I am not under the influence of alcohol or drugs. • I am not pregnant or nursing • I have truthfully represented to the associates, agents, and representatives of North Street Tattoo that I am over eighteen (18) years of age. • I do not have medical or skin conditions such as but not limited to acne, freckles, moles, sunburn, scarring (keloid) eczema, psoriasis or lesions in the area to be tattooed that might interfere with said tattoo. • if I have a history of diabetes, narcolepsy, epilepsy, seizures, fainting, hepatitis, hemophilia, HIV-AIDS or any other communicable disease, heart condition or take medicine which tins the blood I have advised my tattooer. • If I have a history or a history of allergies or adverse reactions to pigments, dyes, ointments, latex or other sensitivities I have advised my tattooer. • I acknowledge that side effects of body art and tattooing including, but not limited to, hypertrophic scarring, adverse reactions to dyes, pigments, inks, may occur up to twenty (20) years after procedure. Tattooing can decrease the ability of physicians and other medicals professionals to locate skin melanoma in regions concealed by tattoos. • I acknowledge that tattoo inks, dyes and pigments have not been approved by federal food and drug administration and the health consequences of using these products are unknown. • I acknowledge that it is not reasonably possible for the associates, agents, employees and representatives or North Street Tattoo to determine whether I might have an allergic reaction to pigments, dyes, or processes used during the process of my tattoo and I agree that tattoo artists do not act as medical professionals, and I hereby agree to accept such risks that may occur. • I acknowledge that variations in color and design may exist between any tattoo as selected by me and as ultimately applied to my body. Including but not limited to fading, brightness of colors, from design to application of design as a tattoo. • I acknowledge that tattooing is a permanent change to my appearance and that no representations have been made to me as to there ability to later change, alter or remove my tattoo. Removal of tattoos requires surgery or medical procedure which may result in scarring of the skin tissue. North Street Tattoo is not responsible for any or all tattoo removal procedures. • I have looked over design, checked the spelling if applicable and give full consent to the application of my tattoo. • I acknowledge that the obtaining of my tattoo is my choice alone and I being of sound body and mind give consent to the application of the tattoo and to any actions or conduct of the associates, agents or representatives of North Street Tattoo that are reasonably necessary to perform the tattoo procedure. • I acknowledge that there is a chance I might feel lightheaded and/or dizzy during or after being tattooed. I agree to immediately notify the practitioner in the event I feel lightheaded, dizzy and/or faint before, during or after the procedure. • I acknowledge that infection is always possible in the event that I do not take proper care of my tattoo. I have been advised of the signs and symptoms of infection that indicate a need to seek medical care. • I agree to follow all instructions provided to me concerning the care of my tattoo. Any touch ups needed because of my own negligence will be done at my own expense. • I agree to release and forever discharge and forever hold harmless North Street Tattoo and its associates, agents, artists and shareholders from any and all claims, damages or legal actions arising from or connected in any way with my tattoo or the procedures and conduct used to apply my tattoo. • I acknowledge the potential risks associated with getting a tattoo. I still wish to proceed with said tattoo application and I assume any and all risks that may arise from tattooing.
*
I acknowledge by signing this release form that I have been given the full opportunity to ask any and all questions I might have about obtaining a tattoo from NORTH STREET TATTOO and its representitives. I acknowledge that I have been advised of the facts and matters set forth below, and I agree to as follows.
*
Signature
*
Today’s Date
*
-
Month
-
Day
Year
Date
Upload ID Photo
*
Submit
Should be Empty: