Ink Parlor Release Form Release Form
Let us do this part
Today's Date:
Fri Aug 14 2020 04:49
Please read & answer
If you are getting a tattoo, Is it Color or Black & Grey*
Waverly Dark Black, ALLEGORY Blak AB10191 AB10194, Waverly bluebird

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

I have NOT had 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.

I further acknowledge that the tattoo should be considered permanent; that said tattoo can only be removed with surgical procedure, and that any effective removal may leave permanent scarring and disfigurement.

I have read this form and confirm that all the information i have given is correct. I understand that this is a consent form and i agree to be legally bound by it.
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.
Date of birth:*
You must be 18 or older
Phone #:*

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