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Tattoo
Let us do this part
Today's Date:
Mon Oct 5 2026 04:53
Practitioner:*
Tattoo Body Location:*
ATTENTION! You must have a legal photo ID for this paperwork, if you are under 18 (16 or older) you MUST have a legal ID along with your legal guardian's ID. Last names OR addresses have to match.
Please read and answer
Y
N
IF YOU HAVE:
- a fever
- flu-like symptoms
- shortness of breath

YOU NEED TO NOTIFY A STAFF MEMBER IMMEDIATELY.
How long has it been since you've last eaten? It's a good idea to do so before hand to increase your blood sugar levels, and reduce the risk of lightheadedness.
 
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.
TO WAIVE AND RELEASE to the fullest extent permitted by law each of the artists 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.
Y
N
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 other's safety). This can include by is not limited to HIV/AIDS, Hepatitis, Herpes, Infection, Staph, Syphilis, Tuberculosis, Gonorrhea.
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.
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. I acknowledge that obtaining this tattoo is my free will and choice.
I do not have a mental impairment that may affect my judgment in getting the tattoo.
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.
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.
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.
I agree to reimburse each of the Artist 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 Virginia in United State 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.
Y
N
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).
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 Imperial Tattoo.
I am not currently experiencing Eczema, Psoriasis, or any other skin disease or rash. I verify that the area getting tattooed is not sunburnt or peeling.
Y
N
Are you allergic to any of the following? Alcohol, antibiotics, Cosmetics, Adhesives, Metals, Soaps, Lotions.

Details: 
Y
N
Do you have diabetes, epilepsy, hemophilia, or a heart condition/take blood thinning medication? Do you have any other medical or skin condition that may interfere with the procedure or healing of the piercing? Are you the recipient of an organ or bone marrow transplant? If you are, have you taken the prescribed preventive regimen of anti-biotics that is required by my doctor in advance of any invasive procedure such as a tattoo? Are you pregnant or nursing?(If you have any of these medical conditions, click yes and please list below)

Details: 
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.
Legal Name:*
Pronouns:
Chosen name:
Address:
Postcode:
Date of birth:*
 
If you are under 18 your parent/guardian will be required
Age: 
Phone #:*
Email:
Signature:*

Emergency Contact
If something happens, your emergency contact might need to explain your medical history, allergies, or medications.
Name:
Phone #:*
Photo Identification *
Please take photo(s) of your government issued photo IDs and related paperwork
PLEASE TAKE A PHOTO OF THE FRONT OF YOUR STATE ISSUED ID (License, driver's permit, state ID)