Dear Love Body Art
Let us do this part
Today's Date:
Sat Jun 27 2026 10:10
Practitioner:
*
-- Select --
Big Ear Guy
Other
Tattoo Placement:
*
Pure Gold Studio
221 Normal Ave Suite D
Chico, CA 95926
Please read and answer
Y
N
Do you have Covid-19/Flu like symptoms?
*
IF YOU HAVE:
- a fever
- flu-like symptoms
- shortness of breath
YOU NEED TO NOTIFY A STAFF MEMBER IMMEDIATELY.
Y
N
Eaten
*
Have you eaten in the past 2hrs? It's a good idea to eat before hand to increase your blood sugar levels which in turn can help curb some of the pain and make the tattooing process easier for the client and artist.
Risks
*
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.
Healing
*
I understand that the Artist and/or Studio will inform me on how to properly care for my tattoo during the process of healing.
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.
Under the Influence
*
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.
Health
*
I do not have diabetes, 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 anti-biotics. I am not pregnant or nursing. I do not have a mental impairment that may affect my judgment in getting the tattoo.
Y
N
Bloodbourne Pathogens
*
Do you have any bloodbourne pathogens, transmittable diseases or recent illnesses? (It' okay if you do, we just want to know for our and other's safety).
Details:
Y
N
Medications
*
Please list any medications you are currently taking.
We need to know this in case we are aware of any adverse side effects that may hinder your ability to get tattooed or heal successfully.
Details:
Y
N
Allergies
*
Please let us know if you are aware of any allergies you may have, even if they seem unrelated to getting a tattoo.
Details:
Spelling
*
I agree that any lettering in my tattoo has been checked for spelling and neither the Artist nor Studio is responsible for the meaning or spelling of the symbol or text that I have provided them or chosen.
Permanent
*
I understand that 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.
Fading
*
I understand that variations in colour/design may exist between the art I have selected and the actual tattoo. 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.
Y
N
Photography
*
I 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.
Waive
*
I AGREE TO WAIVE AND RELEASE to the fullest extent permitted by law each of the Artist and the Studio 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.
Legal Action
*
I agree to reimburse the Artist and the Studio 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 of California in the United States 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.
Questions
*
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, and I understand that I am signing a legal contract waiving certain rights to recover against the Artist and the Studio.
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:
*
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You must be 18 or older
Age:
Phone #:
Email:
Signature:
*
Sign 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.
Legal Name:
*
Signature:
*
Sign or type signature:
Photo Identification
*
Please take photo(s) of your government issued photo IDs and related paperwork
X