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Tattoo Consent

Let us do this part
Today's Date:
Wed May 8 2024 08:09
Practitioner:*
Ink Brand/color:*
Lot #:*
Artist signature:*


Your artist will fill out the top part of this form regarding Ink & Signature after you have completed the following questions.
Please read and answer
 
Procedure*

In consideration of the mutual covenants contained herein, and in order to induce Alchemy Tattoo and the above named artist to perform the requested services, I agree as follows:
*
I have been fully informed of the inherent risks, associated with the procedure. I fully understand these risks and the attendant risk of injury, which can include, without limitation, infections, scarring, allergic reaction to pigments, gloves and equipment used in connection with the tattoo, difficulty in detection and diagnosis of skin conditions, including cancers.
*
I have had the opportunity to familiarize myself with these risks and understand that only I am able to determine whether these risks are acceptable. I have had the opportunity to ask questions regarding the services to be rendered and am satisfied that all concerns that I have raised have been addressed.
*
I WAIVE AND RELEASE to the fullest extent permitted by law Alchemy Tattoo Collective and each of its owners, agents, employees, contractors 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, indirect and consequential damages, that arise from the procedure, whether caused by the negligence or fault of Alchemy Tattoo Collective or any of its owners, agents, employees, or contractors.
I understand and warrant the following:
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I have been provided instructions on the care of my tattoo while it's healing, and I understand them and will follow them.

I acknowledge that it is possible that the tattoo site or surrounding area can become infected.
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I do not have diabetes, epilepsy, hemophilia, or a heart condition. I am not currently using any blood thinning medication. I have reviewed the information accompanying all medications that I have used within the last ninety days for contradictions concerning tattoos. I do not have any medical or skin condition that may interfere with the application or healing of the tattoo. If I am the recipient of an organ or bone marrow transplant, I have consulted my physician and have properly followed the antibiotic regimen, if any, prescribed by my physician in advance of the Procedure. I am not pregnant or nursing.
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I am not under the influence of alcohol or drugs, and I am voluntarily submitting to the Procedure without duress or coercion. I do not have any mental impairment that may affect my judgement in getting the Procedure.
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Neither Alchemy Tattoo Collective or any of its owners, agents, employees, contractors are responsible for the meaning or spelling of the symbol or text that I have provided to them or chosen as a tattoo.
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Variations in colour/design may exist between the tattoo art I have selected and the tattoo as applied to my body. I also understand that the color and clarity of my tattoo will fade over time. I understand that I am responsible for the cost of any touch up work required for my tattoo.
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For my safety, as well as the safety of the staff and patrons of Alchemy Tattoo Collective, I have disclosed all blood borne pathogens I know my blood to contain.
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A tattoo is a permanent change to my body and can only be removed by laser or surgical methods, that may be costly, painful, and disfiguring, and may not restore my skin to its original appearance.
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I have been advised of Alchemy Tattoo's no refund policy, and understand that I have no right to a refund of any payments following the Procedure.
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I agree to reimburse each of the Artist and the Tattoo Studio for any attorneys' fees and costs incurred in any legal action I bring against either the Artist or the Tattoo Studio and in which either the Artist or the Tattoo Studio is the prevailing party. I agree that the that the courts 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.
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Any controversy or claim arising out of or related to the Procedure, shall be settled by arbitration in accordance with the Commercial Arbitration Rules then in effect of the American Arbitration Association, to be held in St. Louis, Missouri, and judgement upon the award rendered may be entered in any court have jurisdiction thereof.
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This agreement constitutes the entire agreement between the parties with respect to the subject matters hereof.
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This agreement and the rights of the parties hereunder shall be governed by and interpreted in accordance with the laws of the State of Missouri
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If any provision of this agreement, or the application of any such provision to any person or circumstance shall be held to be illegal, invalid, or unenforceable under present or future laws effective during the term hereof, the remainder of this agreement, or the application of such provision to any other persons or circumstances, shall not be affected thereby and shall be construed and enforced as if such illegal, invalid, or unenforceable provision did not comprise a part hereof. In lieu of such illegal, invalid, or unenforceable provision, there shall be added automatically as a part hereof a provision as similar in terms to such illegal, invalid, or unenforceable provision as may be possible and be legal, valid, and enforceable.
Photo Release*
Alchemy Tattoo may take photographs of me and the Procedure. I consent to the reproduction of all such photographs in any medium.
*
I have read over all of Alchemy Tattoo's Covid-19 precautions on their website and have not had any symptoms of Covid-19 in the last 2 weeks.
THIS DOCUMENT CONTAINS A LIMITATION OF LIABILITY DUE TO NEGLIGENCE.

THIS DOCUMENT CONTAINS A BINDING ARBITRATION CLAUSE WHICH MAY BE ENFORCED BY THE PARTIES
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 or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or legal guardian is in complete understanding and concurrence with this agreement.
Name:*
Pronoun:
Address:*
Postcode:
Date of birth:*
If you are under 18 your parent/guardian will be required
Phone #:*
Email:*
Signature:*


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