Body Art Release
Let us do this part
Today's Date:
Mon Mar 23 2026 09:03
Practitioner:*
Signature:*

A Rose From Concrete Body Art Collective
Client Consent and Acknowledgment
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
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:*
 
If you are under 18 your parent/guardian will be required
Age: 
Phone #:
Email:
Signature:*

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