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WAIVER, RELEASE AND CONSENT FORM TO PERFORM TATTOO <br /> THIS DOCUMENT IS TWO PAGES. PLEASE INITIAL EACH PROVISION ON THE LINES PROVIDED <br /> AFTER READING TQSHOW THAT YOU UNDERSTAND EACH PROVISION. <br /> |nconsideration ofreceiving otattoo from (the"4rtist")and <br /> Tobacco City, Inc. (and its employees,apprentices and agents, here and after collectively referred to as <br /> ("theBuainemm^). |agree tothe following: <br /> 0, (clearly PRINT your name)on (date) <br /> have been fully informed mf the inherent risks,associated with getting atattoo.Ufully understand <br /> that these risks, known and unknown,can lead toinjury, including but not limited&minfection, <br /> scarring,difficulties imdetecting melanoma and allergic reactions tmtattoo pigment, latex gloves, <br /> and/or soap. Having been informed of the potential risks associated with getting mtattoo, tstill wish <br /> to proceed with the tattoo application and 0freely accept and expressly assume any and all risks <br /> that may arise from tattooing. <br /> x..............I WAIVE AND RELEASE to the fullest extent permitted by law each of the Artist and the <br /> Business from all liability whatsoever,for any and all claims or causes of action that 1, my estate, heirs, <br /> executors orassigns may have for personal injury orotherwise, indudinganydinectend/oruonseguenUe| <br /> damages,which result or arise from the application of my tattoo,whether caused by the negligence or fault <br /> ofeither the Artist orthe Business,or otherwise. <br /> m...............Both the Artist and the Business have given me the full opportunity to ask any and all questions <br /> about the application of my tattoo and all of my questions have been answered to my total satisfaction. <br /> x...............I am not under the influence of alcohol or drugs,and I am voluntarily submitting to be tattooed <br /> bythe Artist without duress orcoercion. <br /> x...----Jam not allergic holatex orantibiotics. <br /> x.................I do not have a history of herpes infection at the proposed procedure site(where new tattoo is <br /> tobegiven)orahistory ofcardiac valve disease. <br /> x.................I do not have a history of medication use or is currently on any medication, including being <br /> prescribed antibiotics prior to dental or surgical procedures. If so, I have already seek my doctor's advice <br /> and orapproval toreceive new body art tattoo. <br /> x...............|donot have diabetes, epilepsy, hemophilia,mheart condition, nor do|take blood thinning <br /> medication. |donot have any other mmdium|ovoWnconditionthetmayinterferewith1heoppdiceUoncx <br /> healing of the tattoo. I am not the recipient of an organ or bone marrow transplant or, if I am, I have taken <br /> the prescribed preventive regimen of antibiotics that is required by my doctor in advance of any invasive <br /> procedure such as tattooing. I am not pregnant or nursing. I do not have a mental impairment that may <br /> affect myjudgment ingetting the tattoo. <br /> x...............Neither the Artist nor the Business is responsible for the meaning or spelling of the symbol or <br /> text that| have provided tothem orchosen from the flash (deeign)sheets. <br /> x...............Vehadonoinco|oranddeeignmayeximtbetxeentho1attooart| heveoe|ectedondthemotue| <br /> tattoo when it is applied to my body. I also understand that over time,the colors and the clarity of my tattoo <br /> will fade due to unprotected exposure to the sun and the naturallyoccurring dispersion of pigment under the <br /> skin. |also understand that the tattoo art iaPERMANENT. <br /> x...............I release all rights to any photographs taken of me and the tattoo and give consent in advance <br />