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Permanent Cosmetics/Tattoo Consent/Release Form

Let us do this part
Today's Date:
Tue May 13 2025 09:14
Practitioner:*
Artist signature:*


Please read and answer
Y
N
COVID-19*
I confirm that I am not presenting any of the symptoms of COVID-19 including but not limited to:

dry cough
runny nose
sore throat
shortness of breath
loss of sense of taste or smell
fever/temperature: 100.0 degrees
 
How did you hear about us?*
 
Y
N
Eaten*
Have you eaten in the past 4 hours? It's a good idea to before hand to increase your blood sugar levels.
Consent*
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.
Skin Condition*
I do not have acne, freckles, moles, or sunburn in the area to be tattooed that might be agitated by the tattoo process (healing excluded).
Consent*
I have looked over my design, checked the spelling if applicable, and give my full consent to the application of my tattoo.
Medical History*
I acknowledge that I am not pregnant or breastfeeding.
Medical History*
I acknowledge that I am free of communicable disease.
Medical History*
I acknowledge that I do not have epilepsy, hemophilia, a heart condition, nor do I take blood thinning medication. I do not have any other condition that may interfere with the application or healing of the tattoo. I am not the recipient of an organ or bone marrow transplant or, if I am, I have taken the preventive antibiotics. I understand that if I have diabetes or have recently ended chemotherapy, a doctor’s note with consent is required. I do not have a mental impairment that may affect my judgment in getting the tattoo.
Acknowledgement*
I acknowledge that I have truthfully represented to Brows by Mia & Mia Melville that I am over eighteen (18) years of age.
Risks*
I acknowledge it is not reasonably possible for Brows by Mia & Mia Melville to determine whether I might have an allergic reaction to the dyes, pigments, or processes used in my tattoo and I agree to accept that such risks are possible.
Risks*
I acknowledge that infection is always possible as a result of obtaining a tattoo particularly in that event that I do not take proper care of my tattoo, and I have been advised of the signs and symptoms of infection that indicate a need to seek medical care. I acknowledge that I have been fully informed of the inherent risks, associated with getting a tattoo. I fully understand that these risks, known and unknown, can lead to injury, including but not limited to infection, scarring, difficulties in detecting melanoma and allergic reactions to tattoo pigment, latex gloves, and/or soap. Having been informed of the potential risks, I still wish to proceed with the tattoo application and I freely accept and expressly assume any and all risks.
After Care*
I acknowledge receipt of written instructions advising me of proper care of my tattoo and recognize the absolute necessity of following those written instructions. All questions about the body art procedure have been answered to my satisfaction. Brows by Mia & Mia Melville have given me instructions on the care of my tattoo while it's healing, and I understand them and will follow them. 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.
Risks*
I acknowledge that variations in color and design may exist between any tattoos as selected by me and as ultimately applied to my body. I also understand that over time, the colors and the clarity of my tattoo will fade due to natural dispersion of pigment under the skin.
Consent*
I acknowledge that tattooing is a permanent change to my appearance and that no representations have been made to me as to the ability to later change, alter or remove my tattoo. 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.
Consent*
I acknowledge that the obtaining of my tattoo is my choice alone and I consent to the application of the tattoo and to any actions or conduct of Brows by Mia & Mia Melville that are reasonably necessary to perform the tattoo procedure.
Waiver*
I agree to release and forever discharge and forever hold harmless Brows by Mia & Mia Melville from any and all claims, damages, or legal actions arising from or connected in any way with my tattoo or the procedures and conduct used to apply my tattoo and any and all tattoos applied by Brows by Mia & Mia Melville in the future.
Risks*
I acknowledge that tattoo inks, dyes and pigments have not been approved by the federal Food and Drug Administration and the health consequences of using these products are unknown.
Risks*
I acknowledge that there is a chance I might feel lightheaded, dizzy during or after being tattooed. I agree to immediately notify the practitioner in the event I feel lightheaded, dizzy and/or faint before, during or after the procedure.
Consent*
I agree to follow all instructions concerning the care of my tattoo, and that any touch-ups needed because of my own negligence will be done at my own expense.
Video & Photo Release/Waiver*
I release all rights to any photographs and/or video recordings taken of me and the tattoo and give consent in advance to their reproduction in print or electronic form. I hereby grant Brows by Mia & Mia Melville the irrevocable right and permission to use photographs and/or video recordings of me on websites and in publications, social media, promotional flyers, or for any other similar purpose without compensation to me. I understand and agree that such photographs and/or video recordings of me may be placed on the internet. I waive the right to approve the final product. I agree that all such portraits, pictures, photographs, video and audio recordings, and any reproductions thereof, and all plates, negatives, recording tape and digital files are and shall remain the property of Brows by Mia & Mia Melville.
Waiver*
I AGREE TO WAIVE AND RELEASE to the fullest extent permitted by law Brows by Mia & Mia Melville from all liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise from my tattoo, whether caused by the negligence or fault of either the Artist or the Studio, or otherwise.
Attorney Fees*
I agree to reimburse Brows by Mia & Mia Melville for any attorneys' fees and costs incurred in any legal action I bring against either the Artist or the Studio and in which either the Artist or the Studio is the prevailing party. I agree that the courts shall have personal jurisdiction and venue over me and shall have exclusive jurisdiction for the purpose of litigating any dispute arising out of or related to this agreement.
Consent*
I acknowledge that I have been given adequate opportunity to read and understand this document, that any and all of my questions have been answered, that it was not presented to me at the last minute. I understand that by completing this form, a legal contract I am waiving certain rights to recover against Brows by Mia & Mia Melville.
COVID-19*
Brows by Mia & Mia Melville have put in place preventative measures to reduce the spread of COVID-19; however, infection from COVID-19 can happen anywhere and no business can guarantee or completely prevent someone from becoming infected. Further, being in any business could increase your risk of contracting COVID-19.
COVID-19*
To prevent the spread of contagious viruses and to help protect others, I understand that I will have to follow the facility's guidelines. The facilities guidelines can be changed at any time as new information and technology become available.
COVID-19*
I confirm that I have not been in close contact with anyone with COVID-19 symptoms or anyone who has been diagnosed with COVID-19 in the past 14 days.
Acknowledgement & Consent*
I agree to pay Brows by Mia & Mia Melville the total amount due for all services rendered at the time of service.
Acknowledgement & Consent*
I acknowledge that I am aware of Brows by Mia's policy that states there are no refunds on deposits or services.
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
Phone #:*
Email:*
Signature:*


Emergency Contact
If something happens, your emergency contact might need to explain your medical history, allergies, or medications.
Name:
Phone #:*
Photo ID*
Please take photo(s) of your government issued photo IDs and related paperwork.