How did you hear about us?*

Do you have any allergies? Please list them below.*

Do you have Flu like symptoms?* IF YOU HAVE:
-a fever
-flu-like symptoms
-shortness of breath

YOU NEED TO NOTIFY A STAFF MEMBER IMMEDIATELY.

Have you eaten in the past 4 hours?*

Are you pregnant/nursing?*

Bloodbourne Pathogens* Do you have any bloodbourne pathogens, transmittable diseases or recent illnesses? (Example: HIV/Hepatitis B/Syphilis) If so, please check “Y” and list them below. If not, please check “N” and write N/A below. Your answers are confidential.

Risks* I have been fully informed of the inherent risks, associated with getting a tattoo. I fully understand that these risks, know and unknown, can lead to injury, including but not limited to infection, scarring, difficulties in detecting melanoma and allergic reactions to tattoo pigment, latex gloves, and/or soap. Having been informed of the potential risks, I still wish to proceed with the tattoo application and I freely accept and expressly assume any and all risks.

Waive* I WAIVE AND RELEASE to the fullest extent permitted by law each of the artists and Rose Stem Tattoo from all liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise from my tattoo, whether caused by the negligence or fault of either the Artist or the Tattoo Studio, or otherwise.

Aftercare * I understand that after filling out this form, I will receive a confirmation email containing proper aftercare instructions curated by the artists of Rose Stem Tattoo. I acknowledge that it is possible that the tattoo can become infected, particularly if I do not follow the instructions given to me. If any touch-up work to the tattoo is needed due to my own negligence, I agree that the work will be done at my own expense.

Influence* I am not under the influence of alcohol or drugs, and I am voluntarily submitting to be tattooed by the artist without duress or coercion.

Health * I willingly confirm that I do not have diabetes, epilepsy, hemophilia, a heart condition, nor do I take blood thinning medication. I do not have any other condition 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 preventive anti-biotics. I do not have a mental impairment that may affect my judgement in getting the tattoo. I will notify my artist otherwise.

Spelling* Neither the artist nor the studio is responsible for the meaning/spelling of the symbol/text that I have provided to them or chosen from the flash(design) sheets.

Fading* Variations in colour/design may exist between the art I have selected and the actual tattoo. I also understand that over time,the colors and the clarity of my tattoo will fade due to natural dispersion of pigment under the skin.

Permanent * I acknowledge that a tattoo is a permanent change to my appearance and can only be removed by laser or surgical means, which can be disfiguring and/or costly and which in all likelihood will not result in the restoration of my skin.

Legal Action* I agree to reimburse each of the artists and the Tattoo Studio for any attorney’s fees and costs incurred in any legal action I bring against either Artist or the Tattoo Studio and in which either the Artist or the Tattoo Studio is the prevailing party. I agree that the courts of California in the United States 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.

If I am unable to pay the final amount the day of my scheduled appointment, I understand that legal actions may be taken against me. As part of the agreement when booking an appointment, I agreed to the pricing quoted by my artist. I understand that changes in pricing may happen same day due to a number of factors, which will be discussed with my artist prior to the procedure.

Finger/hand tattoos* If I am getting finger or hand tattoos done, I acknowledge that I am responsible for the proper aftercare of the tattoos. I understand that many finger tattoos do tend to fade/disappear overtime (also in a matter of weeks) and that touch-ups may be required. I acknowledge that there is a possibility of infection/illness should I not keep the tattooed area clean. I understand that there will be charges for a touch-up procedure. I am aware that I may contact my artist with any questions or concerns.

Ink Materials * I understand that certain inks/materials are not approved by the FDA. Any complications accounted with the inks and materials used are at my own risk. I understand that I may be subject to allergic reactions and that my artist is not at fault in any case of complications resulting from the tattooing/aftercare process.

Touch-Ups* I understand that touch-ups are not free and will be charged accordingly. I understand that fading may occur overtime and that certain risks are associated with neglecting or ignoring my artist’s aftercare instructions.

Photography * I release all rights to any photographs taken of me and the tattoo and give consent in advance to their reproduction in print or electronic form. (If you wish to not be photographed, please notify your artist.)

Questions* I acknowledge that I have given the time to thoroughly read and understand this document and that I have also been given the opportunity to ask any and all questions I may have. I acknowledge that all the information I have provided is true. I understand that I am signing a legal contract waiving certain rights to recover against the Artist and the Tattoo Studio.

Liability of false information* I understand that the artists/owners of Rose Stem Tattoo are not responsible for any inherit risk associated with my choice to list any false information on this release form. I understand that the information I input is detrimental to both my health/safety and the health/safety of my artist and others. If in any circumstance I am negligent in disclosing important information, or disclose false information,I understand I will be held liable for any repercussions accociated with doing so (affecting myself and/or my artist), including but not limited to:

Illness
Quality of life
Death

Payment * I have discussed pricing with my artist and have the proper payment and payment method as listed on the policy form.

Rose Stem Tattoo DOES NOT accept payment via VENMO or CREDIT/DEBIT/CHECK on the day of your appointment.

I will be paying with the following:*