Tattoo Consent Release Form

Let us do this part
Today's Date:
Sun Nov 29 2020 09:47
Practioner:*
Tattoo Placement :*
Please read and answer
 
How did you hear about us?
 

Y
N
Eaten*
Have you eaten in the past 4hrs? It's a good idea to eat beforehand to increase your blood sugar levels.
Y
N
Payment*
Cash is preferred. We accept all major credit cards, but you will be charged a $5 processing fee for every $100 when using a credit card.
Y
N
Bloodbourne Pathogens*
Do you have any bloodbourne pathogens, transmittable diseases or recent illnesses? (It's okay if you do, we just want to know for our and others' safety).
Risks*
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.
Waive*
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 Tattoo Studio, or otherwise.
Healing*
The Artist and the Tattoo Studio 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.
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.
Spelling*
Neither the Artist nor the Tattoo Studio is responsible for the meaning or spelling of the symbol or text that I have provided to them or chosen from the flash (design) sheets.
Fading*
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.
Permanent*
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.
Legal Action*
I agree to reimburse each of the Artists and the Tattoo Studio for any attorneys' fees and costs incurred in any legal action I bring against either the Artist or the Tattoo Studio and in which either the Artist or the Tattoo Studio is the prevailing party. I agree that the that the courts of The United States of America 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 Tattoo Studio.
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. (If you do not tick this provision, please advise your Artist).
COVID - 19
I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.
I further acknowledge that Great Whale Tattoo LLC has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.
I further acknowledge that Great Whale Tattoo LLC can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, salon staff, and other salon clients and their families.
I voluntarily seek services provided by Great Whale Tattoo LLC and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.
I attest that:
* I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
* I have not traveled internationally within the last 14 days.
* I have not traveled to a highly impacted area within the United States of America in the last 14 days.
* I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.
* I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities.
* I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.
I hereby release and agree to hold Great Whale Tattoo LLC harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the salon, or that may otherwise arise in any way in connection with any services received from Great Whale Tattoo LLC. I understand that this release discharges Great Whale Tattoo LLC from any liability or claim that I, my heirs, or any personal representatives may have against the salon with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Great Whale Tattoo LLC. This liability waiver and release extends to the tattoo shop together with all owners, partners, and employees.
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.
Personal Info
I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement.
Legal Name:*
Prefered name:
Address:*
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.