Consent Form

I acknowledge by signing this form that I have been given full opportunity to ask any and all questions which I might have about obtaining a tattoo. Please initial in the boxes provided after reading to show that you understand each provision.

 

Name: ______________________________________________ Date of Birth: _____/_____/_______

Address:_______________________________________________________ City: ________________

Address Line 2 (opt): ___________________________ State: __________ Zip Code: ____________

 

______ I request the tattoo artist _______________, to tattoo my body. I agree to release and forever discharge and hold harmless the tattoo artist, Main Street Tattoo and all subcontractors from all liability whatsoever including but not limited to, any and all claims, damages, or legal actions arising from or connected in anyway with my tattoo or the procedure and conduct used to apply my tattoo.

 

______ I have trustfully represented to the tattooist I am over the age of 18 years. I am not under the influence of drugs and alcohol. To my knowledge, I do not have any physical, mental, or medical impairment or disability which might affect my well-being as a direct, or indirect, result of my decision to receive a tattoo.

 

______ I acknowledge that obtaining this tattoo is my choice alone and will result in a permanent change to my appearance. No representation has been made to me as to the ability to later restore the skin involved in this tattooing to its pre-tattooed state.

 

______ I do not suffer from medical or skin conditions such as, but not limited to: keloid or hypertrophic scarring, psoriasis, open wounds or lesions at the site of the tattoo.

 

______ I acknowledge infection and/or allergies are always possible as a result of obtaining a tattoo. I agree to follow all instructions concerning the care of my tattoo while it is healing, never touching my tattoo without washing hands first.

 

______ I have advised the tattoo artist of any allergies to metals, latex, wool, soaps and medications. I acknowledge it is not possible for the tattoo artist to determine whether I may have an allergic reaction to the tattoo or process involved while tattooing and further acknowledge such a reaction is possible.

 

______ If I suffer from hepatitis, HIV, other communicable diseases, heart conditions or am currently taking blood thinning medication, I have informed my tattoo artist.

 

______ I agree to release my rights to photographs or other reproductions of the tattoo work the artist has done of my body. I understand that these photos may be used in articles, advertisements, and other print media to further expose the tattoo artist.

 

Any medications you are currently taking: ________________________________________________________

 

Have you eaten in the last 4 hours? ______ Yes ______ No

 

Signature: __________________________________________ Date: _______________________

 

 

Are you getting lettering/text? If so, please write it below:

   ________________________________________________________