Ink'd Expression Arts
Tattoo/Piercing Waiver
First Name
*
Last Name
*
Pronouns
She/Her/Hers
He/Him/His
They/Them/Theirs
Email
*
Phone
*
Address
*
City
*
State
*
Postal code
*
Date of birth
*
Drivers Licence Number
*
Please upload a picture of your drivers licence.
*
Artist Full Name
*
Artist Email Address
*
Artist Booth Number
*
Do you have any allergies?
*
Do you use any medications that might affect the healing of the body art you wish to receive?
*
Do you have any other medical or skin conditions that may affect the outcome of your procedure?
*
Have you ever been prescribed antibiotics prior to dental or surgical procedures?
*
Yes
No
Is there any information you feel you should provide to the body art practitioner?
*
I acknowledge that a tattoo is a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove my tattoo. To my knowledge, I do not have a physical, mental or medical impairment or disability which might affect my well being as a direct or indirect result of my decision to have a tattoo.
*
Yes
No
I am not pregnant!
*
Yes
No
I am nursing/breastfeeding
*
Yes
No
I have a blood borne disease, including Hep C, Hep B, Hep A, HIV/AIDS or any other transferable pathogen.
*
Yes
No
I fully understand and acknowledge that tattoo inks, dyes, and pigments are not regulated in Canada and have not been approved by the US Federal Food and Drug Administration, and that the health consequences of using these products are unknown. The tattoo inks may or may not contain metals, consisting of nickel, cadmium, and chromium, and could render me ineligible for Magnetic Resonance Imaging (MRI) tests.
*
I agree
I fully understand and accept that there are risks, both known and unknown, associated with getting a tattoo, which can lead to injury, including but not limited to, infection, permanent scarring/Keloid scarring, difficulties in detecting melanoma, and allergic reactions to tattoo pigment, latex gloves, and/or soap
*
I understand
I do not have diabetes, epilepsy, hemophilia, any heart conditions, nor do I take blood thinning medication. I do not have any medical or skin 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 prescribed preventive regimen of antibiotics that is required by my doctor in advance of any invasive procedure such as tattooing. I am not pregnant or nursing/breastfeeding. I do not have a mental impairment that may affect my judgment in getting a tattoo. I have disclosed to the Artist of any blood borne diseases, including Hep C, Hep B, Hep A, HIV/AIDS and any other transferable pathogen. I have disclosed all or any medical issues which may complicate or interfere with proper healing of a tattoo or that may affect the staff or the environment during the process of giving me the tattoo.
*
I agree
A tattoo is 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 to its exact appearance before being tattooed.
*
I understand
Neither the Artist nor the Tattoo Studio is responsible for the meaning or spelling of the symbol or text that I have provided to them or chosen from the flash (design) sheets.
*
I understand
Variations in colour and design may exist between the tattoo art I have selected and the actual tattoo when it is applied to my body. I also understand that over time, the colours and the clarity of my tattoo will fade due to unprotected exposure to the sun and the naturally occurring dispersion of pigment under the skin.
*
I understand
I release all rights to any photographs taken of me and the tattoo and give consent in advance to their reproduction in print or in electronic form. **Note; If you do not initial this provision, please advise and remind your Artist and the Tattoo Studio NOT to take any pictures of you and your completed tattoo.
*
I do
I do not
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.
*
I agree
I am eighteen (18) years old and am of legal age and have provided valid proof of age to the Tattoo Studio. I am mentally competent to sign this Agreement.
*
I agree
I acknowledge that infection is always possible as a result of the obtaining of a tattoo, particularly in the event that I do not take proper care of my tattoo. I have received aftercare instructions and I agree to follow them while my tattoo is healing. I agree that any touch-up work needed, due to my own negligence, will be done at my own expense.
*
I agree
Signature
*
Clear
Submit Form
Powered by:
