←
Body Art Release
Let us do this part
Today's Date:
Sat May 4 2024 10:09
Practitioner:
*
-- Select --
Donell
Marie
Randi
Greg
Lindsey
Solo
Lauren
Raina
Tori
Keighlee
McKenzie
Chance
Other
Artist signature:
*
Utah
Please read and answer
Y
N
*
Have you been tattooed before?
Y
N
*
Are you pregnant? If not please mark no
Y
N
*
Are you on any medication? If so please list them to the best of your knowledge.
Details:
Y
N
*
Do you have any allergies?
Details:
Y
N
*
Do you have a heart condition, bleeding disorder, diabetes, or have ever had a seizure?
Details:
Y
N
*
I have eaten within one hour prior to the start of this session
*
I am not under the influence of drugs or alcohol.
*
I understand and agree that if I have had alcohol or illegal drugs in my system in the last 48 hours you can directly affect the healing of my tattoo.
Y
N
*
I understand that the tattoo may vary in appearance, color, design from the image the design is based off and the placement of the tattoo and/skin tones.
*
I am aware that this tattoo is permanent, and it can only be removed via laser, which can produce scaring.
Y
N
*
Do you have any blood borne illnesses or communicable diseases such as hepatitis, HIV or AIDS? Or any infections, bacteria, or fungus, that are not bleeding being treated? Are you on medication for them if so what kind? If yes please explain.
Details:
*
I am aware there are no refunds on tattoo deposits and costs and all funds are non-transferable but the end cost of the tattoo will vary for many reasons and exact cost cannot be given at all times
Y
N
*
Are you currently experiencing any flu type symptoms
I agree to pay for any and all damages and/or injuries to any persons in Black Art Society.
I confirm that all information above is true.
I understand that pictures taken of me/my tattoos can be posted on social media and other platforms.
I agreed to hold harmless from all damages, actions,, clean judgments, course of litigation, attorneys fees and other costs of expenses which might arise from my decision to have any tattoo work done at the Black Art Society.
I hereby release any and all employees, agents, or persons representing the Black Art Society from all responsibility and agree not to sue in connection with any and all damages, claims, demands, rights and causes of actions of any nature based upon injuries or property damages to or death of myself or any other persons arising from my decisions to have a tattoo done at this time.
If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.
Client Information
I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or legal guardian is in complete understanding and concurrence with this agreement.
Name:
*
Address:
Postcode:
Date of birth:
*
-Month-
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
-Day-
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
-Year-
1914
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
If you are under
18
your parent/guardian will be required
Gender:
Phone #:
*
Email:
*
Sign up for our newsletter
Signature:
*
Sign above or type signature:
Parent/Legal Guardian
I, as custodial parent or legal guardian of the above minor under 18 years of age, hereby consent to the terms and conditions set forth in this release form and I attest that all documentation I have provided is true and accurate.
If you are 17 you need a parent present and the must have proper ID. If your 16 you must turn around and leave the shop.
Guardian's Legal Name:
*
Relationship:
*
-select-
Natural guardian (birth parent)
Legal parent via marriage
Legal guardian via adoption
Other (provide proof)
Signature:
*
Photo ID
*
Please take photo(s) of your government issued photo IDs and related paperwork.
Remove Photo