TATTOO RELEASE FORM Name * First Name Last Name DATE OF BIRTH * AGE * Phone (###) ### #### Placement of tattoo * please describe desired tattoo placement 1. I am at least 18 years of age: * YES 2. Do you have a heart condition? * YES NO 3. Are you taking an blood thinning medications or antibiotics? * YES NO 4. Do you have any mental, physical, or medical impairment or disability, to your knowledge, which may affect your well being as a direct or indirect result of having a permanent tattoo procedure performed? * YES NO 5. Do you have epilepsy? * YES NO 6. Have you had hepititus within the last year? * YES NO 7. Are you a hemophiliac? * YES NO 8. Are you pregnant? * YES NO 9. Are you under the influence of any drugs or alcohol? * YES NO 10. I to the best of my knowledge am free of any medical conditions which would prevent me from properly healing a tattoo: * YES NO I am of sound mind and body and lawful age. I have answered the above questions truthfully and to the best of my knowledge. I understand and agree that there are potential risks associated with the application of the permanent tattooing process, including but not limited to: 1. There may be discomfort or pain 2. There is a possibility of allergic reaction to pigments, adhesives, or other items used. 3. There is a risk of infection, especially if aftercare instructions are not followed. * AGREE I DO NOT AGREE Furthermore, I understand and agree to the permanent nature of tattoos, I also acknowledge the variables which are including, but not limited to: 1. Poor or no aftercare 2. Rough or Blemished Complexion, Scarring, Hypopigmentation, Hyperpigmentation 3. Heavily Melanated Skin Tone 4. Excessive Tanning, or Deeply Tanned Skin Tone Which may affect the final outcome of the tattoo. Knowing this, I expressly and voluntarily release The Hiding Spot, its representatives, contractors and employees, or anyone who may be directly or indirectly related to them from any claims or causes of action, including but not limited to property damage and personal injury. I further assert that I have read and understand all of the above information, and I have beengiven the full opportunity to ask any and all questions which I might have about obtaining a tattoo from The Hiding Spot, I have recieved my care instrction sheet, and understand the necessity of following those instructions. * I.D. NUMBER * Thank you!
