Tattoo Release Form
Tattoo Consent
Participant Information
Full Name
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First Name
Last Name
Age
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Date of Birth
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Month
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Day
Year
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Phone Number
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Area Code
Phone Number
Email
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example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please, attach a photo of your ID
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CHOOSE A FILE
This is required as proof that you are over 18 years old
Cancel
of
Appointment Date
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Month
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Day
Year
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Pre-Procedure Questionnaire
Are you under the influence of drugs or alcohol?
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Yes
No
Are you pregnant or nursing?
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Yes
No
Do you have a communicable disease?
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Yes
No
Do you have low blood sugar?
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Yes
No
Do you haveany skin conditions?
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Yes
No
Will this beyour first tattoo experience?
Yes
No
Skin conditions (e.g. Rashes, eczema, infection, psoriasis, freckles, etc.)
If yes, please identify the condition.
Medical History (e.g. DIabetes, Cardiovascular Disease, Epilepsy, Blood-related disease etc.)
If yes, please identify the condition.
Acknowledgment and Waiver
By clicking on the circles, you are agreeing to the following:
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I am aware of the potential risks associated with getting a tattoo, and still wish to proceed with the tattoo process. I freely accept any and all risks that may arise from tattooing. These inherent risks include but are not limited to: infection, scarring, difficulty in detecting skin conditions/illnesses, and allergic reactions.
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To my knowledge I do not have any mental or physical impairment, disability, or health condition which could affect my wellbeing as a direct/indirect result of getting tattooed.
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If I have a communicable disease, heart condition, or take medicine that thins the blood I have advised my tattooist.
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I am not pregnant or nursing.
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I am not under the influence of alcohol or drugs
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I do not have medical or skin conditions such as but notlimited to: acne, scarring (Keloid), Eczema, psoriasis, rash, infection,lesion, freckles, moles or sunburn in the area to be tattooed that mayinterfere with said tattoo. If I have any type of infection, rash, or lesionanywhere on my body, I will advise my tattooist.
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- I acknowledge it is not reasonably possible for there presentatives and employees of this tattoo shop to determine whether I might have an allergic reaction to the pigments or processes used in my tattoo, and I agree to accept the risk that such a reaction is possible.
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I understand that this procedure is a permanent change to my skin and body
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I allow my tattoo to be photographed and used for the tattoo artist's or studio's portfolio showcase.
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I accept and understand that payment for the tattoo artist's work is non-refundable
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I have received aftercare instructions and I agree to follow them while my tattoo is healing. I agree that any touch-up work needed, due to my own negligence or failure to follow such instructions, will be done at my own expense.
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I realize that variations in color and design may exist between any tattoo as selected by me and as ultimately applied to my body.
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I understand that if I have any skin treatments, laser hair removal, plastic surgery, or otherskin-altering procedures, it may result in adverse changes to my tattoo.
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I acknowledge I am over the age of eighteen and that I have truthfully represented to my tattooist that the obtaining of a tattoo is by my choice alone.
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I acknowledge that a tattoo is a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove my tattoo. To my knowledge, I do not have a physical, mental, or medical impairment or disability which might affect my well-being as a direct or indirect result of my decision to have a tattoo.
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I consent to the application of the tattoo and to any actions or conduct of the representatives and employees of the tattoo shop reasonably necessary toper form the tattoo procedure.
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To have Zozulenko Alena tattooed on my body, and inconsideration of agreeing to do so, I release the tattoo studio, its owners andagents, and the tattoo artist performing my tattoo, from all liabilities,claims, actions, and demands at law or in equity that I or my heirs may havenow or in the future in connection with the fulfillment of my request for atattoo. I understand that the tattoo will be applied using appropriate toolsand techniques to ensure proper healing of my tattoo. I agree to follow the proceduresoutlined in the tattoo care instructions until complete healing. I understandthat it takes 1 month or more for my tattoo to fully heal. I certify that I amat least 18 years of age. I certify that all of the above information is trueto the best of my knowledge and by signing, I certify that all of the above istrue
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I am voluntarily submitting to be tattooed by the Artist without duress or coercion.
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I agree that I have been given adequate opportunity to read and understand this document, and I understand that I am signing a legal contract waiving certain rights and releasing the artists and studio from liability for my decision to get tattooed
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I confirm that the information I provided in this document is accurate and true.
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I consent to the use of all provided information
Signed Date
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Month
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Day
Year
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Participant Signature
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Submit
Submit
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