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Patch test

Let us do this part
Today's Date:
Sun Jul 13 2025 04:08
Practitioner:*
Inks used:*
Other notes:*
Hello and welcome to Mrs Ms, this is your disclaimer for your appointment, please read it carefully and fill in all the relevant information. Have a great day.
Please read and answer
Risks*
I understand that there are risks associated with getting a patch test of a tattoo and I have been made aware of these risks. I understand that these risks known or unknown, can lead to injury, including but not limited to infection, scarring, difficulties detecting melanoma and adverse reactions to tattoo pigments, latex gloves, and/or soap. Having been informed of the potential risks, I still wish to proceed with the tattoo patch test and I freely accept any potential risks.
Y
N
Have you eaten *
I am fully aware of the implications if I have not eaten before getting my tattoo patch test and that my artist may refuse to carry out the patch test and that I will still be liable for any costs associated with the appointment. I understand I may become unwell, pass out or throw up if I've not eaten.
Y
N
Bloodbourne pathogens *
Do you have any transmittance diseases or have you been unwell recently. It's OK if you do, no judgement here.
Waiver*
I agree to waive and release to the fullest extent permitted by law, each of the artists and studio from any liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors, or assigns may have for my personal injury or otherwise. Including any direct and/or consequential damages, which result or arise from my tattoo patch test whether caused by the negligence or fault of either artist or the tattoo studio, or otherwise.
Healing and aftercare*
The artist and tattoo studio have given me verbal and written nstructions on the care of my tattoo while it's healing and I understand them and will follow them. I have also been recommended aftercare products to purchase and should I chose not to purchase then the tattoo may not heal at its best. I acknowledge that it is possible that the tattoo can become infected, particularly, if I do not follow the instructions given to me.
Duress*
I am not under the influence alcohol or recreational drugs and I am voluntarily submitting to being tattooed for a patch testby the artist without duress or coercion.
Health and illnesses*
I do not have any serious illness such as but noy limited to, diabetes, hemophilia, heart conditions nor do I take blood thinners or any other medications that may interfere with the application or healing of the tattoo. I am not the recipient of an organ or bone marrow transplant or if I am I have taken the preventative anti biotics and am 12 months post healing. I am not pregnant or nursing, I do not have any mental impairment that may affect my judgement in getting the patch test.
Permanent changes *
I understand that a tattoo is a permanent change to my appearance and can only be removed by laser removal and can be costly should I wish to remove it and that my skin may not return to its original state.
Legal action*
I agree to reimburse each of the tattoo artists and studio for any solicitors fees and costs incurred in any legal action I may bring against either the artist or studio should either party be prevailing. I agree that the courts of Wales UK 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.
Questions*
I have been given the opportunity to ask any questions and they have been answered sufficiently, I have been given adequate time to read the fill out this document and fully understand it. I understand that I am signing a legal document and I am wavering certain rights.
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.
Legal Name:*
Pronoun:
Chosen name:
Address:*
Postcode:*
Date of birth:*
You must be 18 or older
Phone #:*
Email:*
Signature:*


Emergency Contact
If something happens, your emergency contact might need to explain your medical history, allergies, or medications.
Name:
Phone #:
Photo ID*
Please take photo(s) of your government issued photo IDs and related paperwork.