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12 McWeys Tattoo — ConsenWaiver READ AND CHECK THE BOXES WHEN YOU ARE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SIGNING (FILL OUT BOTH SIDES OF FORM) I being eighteen(18)years of age or older,hereby consent to a tattoo to be conducted by"12 Monkeys Tattoos"or an agent or employee of the same as follows: Tattoo description: Location on body: Artist: Price: I understand "12 Monkeys Tattoos"has taken appropriate steps to ensure sanitary conditions for said tattoo. More specifically, I have initialed the areas below indicating: Only single use sterile needles are used,and are disposed of in a medical sharps container after every tattoo. The pigments and supplies that will be used in the application of the tattoo are single use per customer. I have received and read the aftercare information,and s� steps necessary for safe,sanitary maintenance. I acknowledge by signing this agreement that I have _=go It 1 op�pd #� $ ly and all questions which I might have about ti lU 'tYu' obtaining of a tattoo and that all of my question ! een a ered to my full sail- X4 `i ically acknowledge I have been advised of the facts and matters set forth below and I agj'r� r have i ed the areas i fall ws MAW, 11,1111111 ) r � � �, , I am not under the influence of drug mor alc I ol. To an d (, any phy � �dental or medical impairments or disability which might affect my wellbeing as a direct or inch my �to have tattoo done at this time. I understand that there is aloha I might feel lig e Y 21,`t�5 y or an uring or aftkv,Igoing tattooed and agree to immediately notify ?� A �,�r' � �, �, i a t SaiF� the practitioner in the event I f j �� ed,diz aint befo dun raft f cedure I acknowledge that obt t t e an irera cy a ar # ghat no representation has been made to me as to thea ttoo tol, R atto� n rz I understand that tatt 1 permaif I choose to have it r may be t ensive , eave scars. ��, tri I acknowledge it is no onably possible o t} s of this too siopetermine whether I might have If ar ) 4ri(�ktGtihr�@ sf 3 .r {i an allergic reaction to the pi is or processes u� Io �cept the rf k `t such a eatztion is possible I acknowledge that in 'on is always possible tattoo rttc arl (ie tit that I do not take proper care of my tattoo. I have re Iced aftercare instructions and I ag," - 1 while -attfr is,4 I ee that any touch-up work needed,due to my own negl ce,will be done at my own expess��tik � l I realize that variation or and desi n may exist betwee �s se u, rid/or the art� nd is ultimate) applied to g Y - � � Y pP my body. I understand that I olor is dark the colors will no � br)g s toy p l�gh akin , N have b� -�C4Cl1le1 oar risks of tatty i' qng including but not limited to infection,scarring,difficulties in ting elanoma,and allergic reactio ipigme°rex glove id antibiotics. Having been U informed of the potential risks asso "�getting a tattoo,I still wish to eed with tattoo apple and I assume any and all risks that may arise from tattooing. � k 4 INS? ��'�� i�jj� � p�� i�y�n�i `r ,� �_y�m =a rb- 15' I agree to pay the above price in full at the time— endere In��nsideration for th .t2ftoo services performed at my request,I y,W ,f release"12 Monkeys Tattoos"and any of its employees,M ontractors ora srEi eof,from all claims and rights of actions of an kind � �vt , g Y which I now have or which may accrue,arising out of the above sli- t� d'tacrservices and related activities,including but not limited to: claims of personal injury,property damage and other losses incurred as a result(direct or indirect)of said tattoo services,including injuries, damages and losses which are presently known as well as those which may develop or be discovered in the future. I further waive all of said claims and rights of action. I have read this document and understand the procedure and any potential risks thereof and agree to all of its contents. I represent that all information provided by me on this form and verbally is true and accurate. NAME: DATE OF BIRTH ADDRESS: PHONE( ) DRIVERS LICENSE# STATE EMAIL: (if you wish to receive upcoming event information) CUSTOMER/CLIENTS SIGNATURE ARTIST SIGNATURE DATE: DATE: