Ink Parlor East Release Form Release Form

←

Let us do this part

Today's Date:

Wed Oct 16 2019 07:10

Artist:*

Please read & answer

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 to have this procedure done.

Phone #:*

Email:*

Signature:*

Photo ID(s)*

Please take a picture of your government issued photo ID