Artist
*
Manny Lorenzana
Karen Haze
Rene Ceniceros
David Abergel
Tattoo Design
*
Placement
*
Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Date of Birth
*
Provision #1
*
I have been fully informed of the inherent risks associated with getting a tattoo. Therefore, I fully understand that these risks, known and unknown, can lead to injury including but not limited to: infection, scarring, difficulties in the detection of melanoma and allergic reactions to tattoo pigment, latex gloves and/or soap. Having been informed of the potential risks associated with getting a tattoo I wish to proceed with the tattoo procedure and application and freely accept and expressly assume any and all risks that may arise from tattooing.
Provision #2
*
TO WAIVE AND RELEASE to the fullest extent permitted by law each of the practitioners and the “facility” 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 the application of my tattoo procedure, whether caused by the negligence or fault of
either the practitioner, facility or otherwise.
Provision #3
*
I agree to reimburse the practitioner and the facility for any/all attorneys’ fees and costs incurred in any legal action I bring against either the
practitioner or the facility and in which either the practitioner or the facility is the prevailing party. I agree 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.
Provision #4
*
Neither the practitioner nor the facility is responsible for the meaning or spelling of symbols or text that I provide to them, or that is chosen from
the example design sheets or hand-drawn and designed by my direction.
Provision #5
*
Variations in color and design may exist between the body art procedure I have selected and the actual tattoo when it is applied to my body. I
also understand that over time, the colors, 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.
Photography Release
*
I release all rights to any photographs taken of me and the procedure site and give consent in advance to their reproduction in print or electronic form.
Provision #6
*
The Tattoo Studio has given me instructions on the care of my tattoo while it's healing. I understand 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.
Provision #7
*
I am not under the influence of alcohol or drugs, and I am voluntarily submitting to be tattooed by the Tattoo Studio without duress or coercion.
Provision #8
*
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 to its exact appearance before being tattooed.
Provision #9
*
I agree that the Tattoo Studio has a NO REFUND policy on tattoos, piercing and/or retail sales and I will not ask for a refund for any reason whatsoever.
Provision #10
*
I am not under the influence of alcohol or drugs, and I am voluntarily submitting to the application of a tattoo procedure by the practitioner without duress or coercion
Provision #11
*
I hereby declare that I am of legal age (and have provided valid proof of age and identification) and am competent to sign this Agreement.
Provision A
*
I do not suffer from diabetes, epilepsy, hemophilia, heart condition(s), nor do I take blood thinning medication. I do not have any other medical or skin condition that may interfere with the procedure, 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 preventative regimen of antibiotics that is required by my doctor in advance of any invasive procedure such as tattooing or piercing. I am not pregnant or nursing. I do not have a mental impairment that may affect my judgement in getting the tattoo.
Provision B
*
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 a tattoo procedure. I have not ingested anti-coagulants, anti-platelet or
NSAIDS (aspirin, ibuprofen, etc.) which may inhibit the ability to heal my skin. I do not suffer from narcolepsy. I will consult a physician prior
to the procedure if I have any concerns about any of these questions.
Check all that Apply
*
If none apply, select non-applicable, "N/A"
Check all that Apply Continued
*
If none apply, select non-applicable, "N/A"
Other Skin Conditions:
*
If none, please type N/A
Current Medications
*
If none, please type N/A
Past Medications
*
If none, please type N/A
Provision C
*
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.
Provision D
*
The Tattoo Studio has given me the full opportunity to ask any question about the procedure and application of my tattoo and all of my questions, if any, have been answered to my total satisfaction.
Provision E
*
I acknowledge that I have been given adequate opportunity to read and understand this document that it was not presented to me at the last minute and grasp that l am signing a legal contract waiving certain rights to recover damages against the Tattoo Studio.
Provision F
*
I HAVE READ THE AGREEMENT, I UNDERSTAND IT, AND I AGREE TO BE BOUND BY IT.
