Tattoo Release Form Name * First Name Last Name Email * Phone (###) ### #### Latex Allergy * Do you have, or have you ever experienced an an adverse reaction to latex? Yes No COVID-19 * Are you currently experiencing symptoms of COVID-19 or have you tested positive in the last 2 weeks? Yes No Do you have Flu like Symptoms? * If you have a fever, flu like symptoms, shortness of breath, please let a staff member know immediately. Yes No Have you eaten in the last 4 hours? * It's a good idea to eat before hand to increase your blood sugar levels. Yes No Bloodbourne Pathogens * Do you have any bloodbourne pathogens, transmittable diseases or recent illnesses? (It's okay if you do, we just want to know for our and other's safety.) Yes No Risks * I have been fully informed of the inherent risks, associated with getting a tattoo. I understand that these risks, known 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 tattoo application and I freely accept and expressly assume any and all risks. Yes No Waive * TO WAIVE AND RELEASE to the fullest extent permitted by law each of the Artist and the Studio from all liability whatsoever, for any and all claims of 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 wither that Artist or Tattoo Studio, or otherwise. Yes No Healing * The artist and the Tattoo Studio have given me instructions on the care of my tattoo while it's healing, and I understand them them and will follow them. 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. Yes No Influence * I agree I am not under the influence of alcohol or drugs, and I am voluntarily submitting to being tattooed by the Artist without duress or coercion. Yes No Health * Please indicate YES if you have Diabetes, epilepsy, hemophilia, a heart condition, or if you take blood thinning medication. Please indicate YES if you have any other condition that may interfere with the application or healing of the tattoo. Please indicate YES if you are the recipient of an organ or bone marrow transplant or, if you are, you have taken the preventative antibiotics. Please indicate YES if you are pregnant or nursing. Please indicate YES if you have a mental impairment that may affect your judgement in getting the tattoo. If you indicated YES to any of the above, please provide details. Yes No Spelling * I agree that neither the Artist nor the Tattoo Studio is responsible for the meaning or spelling or the symbol or text that I have provided to them. Yes No Fading * Variations in color/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 and how well I take care of the tattoo both during and after healing. Yes No Permanent * I understand a tattoo is permanent change to my appearance and can only be removed by laser or surgical means, which can be painful, disfiguring, and/or costly and which in all likelihood will not result in the restoration of my skin. Yes No Legal Action * I agree to reimburse each of the Artist and Tattoo Studio for any attorneys' fees and costs incurred in any legal action I bring against either the the Artist or Tattoo Studio and in which either the Artist or the Tattoo Studio is the prevailing party. I agree that the courts of Tennessee shall have personal jurisdiction an venue over me and shall have exclusive jurisdiction for the purpose of litigating any dispute arising out of or related to this agreement. Yes No Thank you!