Ink Parlor East Release Form Release Form

Let us do this part

Today's Date:

Tue Jan 19 2021 08:00

Practioner:*

ice blue 007-2 : magenta 001-2-gl31 : opaque grey 007-2 : Bimini Blue 007-2: White 53020620: Atomic Yellow 002-2: Ole Yellow 007-2: Yellow Ochre 005-2-GL37: Orange 007-2: Really Red 006-2-GL43: Crimson Red 006-2-GL42: Tangelo 012-2: Brick Red 37-041819: Eagle Brown 007-2: Burnt Sienna 003-2-GL34: Flaming Pink 003-2-GL34: Bubblegum Pink 002-2: Smokey Grey 003-2-GL34: True Purple 47-102319: Pretty Purple 009-2: Bluebird 012-2: Blue Steel 008-2: Tahitian Teal 002-2: Spring Green 009-2: Phthalo Green 008-2: Emerald Green 001-2: Spearmint 008-2: Waverly Dark Black

Please read and answer

If you are getting a tattoo, Is it Color or Black & Grey*

I have NOT had any of these symptoms in the last 14 days*

Fever, Cough, Shortness of breath or difficulty breathing, Chills ,Repeated shaking with chills, Muscle pain, Headache, Sore throat, New loss of taste or smell

Name (First,Middle,Last)*

Date of Birth*

Driver's License Number*

Tattoo or Body Piercing*

Are you currently or have you ever used medications that contain a controlled substance?*

Have you ever been diagnosed by a medical doctor as to having contracted communicable disease such as HIV, Hep B and/or other blood borne pathogens?*

Have you ever been diagnosed by a medical doctor as having allergies?*

Have you recently been diagnosed by medical doctor as to having disease that could affect the healing process,including diabetes?*

Are you currently under the influence of illegal substances?*

Are you currently under the influence of an alcoholic beverage? *

Have you been diagnosed with jaundice within the past twelve months?*

Are you currently using any medications that contain blood thinners?*

Are you currently using any medications that weaken the immune system that fights infections?*

I acknowledge that I am aware certain medical conditions and treatments and/or medications used to treat those medical conditions may be adversely impacted by the procedure(s) of tattooing and/or body piercing. Such medical conditions include but are not limited to, impaired kidney and/or liver function,diabetes,jaundice,medications containing blood thinners and medications that weaken the immune system.

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.

Name:*

Address:

Date of birth:*

You must be 18 or older

Phone #:*

Email:*

Signature:*

Sign above or type signature:

Photo ID*

Please take photo(s) of your government issued photo IDs and related paperwork.