Release Form

Full Name

First NameLast Name

Age

Date of Birth

MonthDayYear

Phone Number

Area CodePhone Number

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please, attach a photo of your ID

CHOOSE A FILE

This is required as proof that you are over 18 years old

Appointment Date

MonthDayYear

Are you under the influence of drugs or alcohol?

Are you pregnant or nursing?

Do you have a communicable disease?

Do you have low blood sugar?

Do you haveany skin conditions?

Will this beyour first tattoo experience?

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.

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

Signed Date

MonthDayYear

Participant Signature

Tattoo Release Form

Participant Information

Pre-Procedure Questionnaire

Acknowledgment and Waiver