Ink Parlor East Release Form Release Form

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Let us do this part

Today's Date:

Mon Jul 26 2021 12:31

Practioner:*

Please read and answer

I have NOT been in contact with anyone who tested positive for Covid-19 in the past 14 days.*

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

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

Name (First, Middle, Last)*

Date of Birth*

Driver's License Number*

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:

Postcode:

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.