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Survivors Ink
Let us do this part
Today's Date:
Thu Apr 25 2024 12:04
Practitioner:*
Please read and answer
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N
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In consideration of receiving a tattoo from (the Tattoo Artist) and Survivors Ink, (and its contractors, apprentices, affiliates and agents, here and after collectively referred to as (The Tattoo Studio), I agree to the following provisions.
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Tattoo location is correct? Please notate Tattoo / Procedure location, ie breasts.
Details:
 
 
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Please provide your Breast Cancer diagnosis date?
 
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Was Chemo, or Radiation treatment received?
Y
N
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Were any of your lymph nodes removed?
Details:
 
Y
N
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Breast reconstruction date?
Details:
 
Y
N
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Is anymore breast surgery required?
Details:
 
Y
N
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Surgical or medical complications?
Details:
 
Y
N
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Are you currently taking any medications?
Details:
 
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N
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I have discussed this procedure with my Doctor?
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I fully understand that these risks, known and unknown, can lead to injury, including but not limited to scarring, infection, difficulties in detecting melanoma, allergic reactions to tattoo pigment, aesthetic, latex gloves, and/or soap. I also state that I have not excluded any important health condition that I have had or may have. I have been informed of the potential risks associated with getting a tattoo, yet I wish to proceed with the tattoo application and I freely accept and expressly assume any and all risks that may arise from tattooing.
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Both the Artist and the Tattoo Studio have given me the full opportunity to ask any and all questions about the application of my tattoo and all of my questions have been answered to my total satisfaction
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The Artist and the Tattoo Studio will give me instructions on the aftercare of my tattoo on completion.

I acknowledge that it is possible that the tattoo can become infected, particularly if I do not follow the instructions given to me. If any touch-up work to the tattoo is needed due to my own negligence, I agree that the work will be done at my own expense
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I am NOT under the influence of alcohol or drugs, and I am voluntarily submitting to be tattooed by the Artist without duress or coercion
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A tattoo is a permanent change to my appearance and can only be removed by laser or surgical means, which can be disfiguring and/or costly and which in all likelihood will not result in the restoration of my skin to its exact appearance before being tattooed
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N
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Do you have diabetes, epilepsy, haemophilia, a heart condition or I take blood thinning medication. I have any other medical or skin condition that may interfere with the application or healing of the tattoo. I am the recipient of an organ or bone marrow transplant or, if I am, I have taken the prescribed preventive regimen of antibiotics that is required by my doctor in advance of any invasive procedure such as tattooing or piercing. I am pregnant or nursing. I have a mental impairment that may affect my judgment in getting the tattoo
Details:
 
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Variations in colour and design may exist between the tattoo art I have selected and the actual tattoo when it is applied to my body. I also understand that over time, the colours and the clarity of my tattoo will fade due to unprotected exposure to the sun and the naturally occurring dispersion of pigment under the skin
Y
N
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Do you release all rights to any photographs taken of me and the tattoo and give consent in advance to their reproduction in print or electronic form.

(Please advise and remind your Artist and the Tattoo Studio NOT to take any pictures of you and your completed tattoo!)
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N
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I acknowledge that I have been given adequate opportunity to read and understand this document, that it was not presented to me at the last minute, and I understand that I am signing a legal contract waiving certain rights to recover against the Artist and the Tattoo Studio
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N
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I understand that Survivors Ink is a non profit charity and is run solely on donations and tattoo artists donating their valuable time.

Donations can be made in person, or via www.survivorsink.com.au
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.

I hereby declare that I am of legal age (and have provided valid proof of age) and am competent to sign this Agreement.
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.
Name:*
Address:*
Postcode:
Date of birth:*
You must be 18 or older
Gender:
Phone #:*
Email:*
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Signature:*


Photo ID*
Please take photo(s) of your government issued photo IDs and related paperwork.