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By completing and signing this form, | acknowledge that |have been given the full opportunity tQask any and <br />all questions which | might have about obtaining atattoo from Valley B|uernoon TATTOO STUDIO and that all <br />of my questions have been answered to my full and total satisfaction. I specifically acknowledge that |have <br />been advised of the facts and matters set forth, and I agree as follows (Please initial each statement below): <br />MT | have truthfully represented to Valley B|Wemoon TATTOO STUDIO that ! am over eighteen MEA years <br />of age. <br />MT | acknowle dge that itianot reasonably possible for tfi�e representatives -and g'Of Valley <br />B|uennoon TATTOO STUDIO to determine whether | might have an allergic reaction to the dyes, <br />pigments or processes used in my tattoo, and I agree to accept the risk that such a reaction is <br />possible. <br />&8T I acknowledge that I have advised my tattoo artist of any condition that might affect the healing of <br />this tattoo. | do not have medical Or shin conditions such as but not limited to: acne, scarring (Keloid), <br />eczema, psoriasis, freckles, moles, or sunburn in the area to be tattooed that may interfere with said <br />tattoo, |f|have -any type of infection or rashanon -my body, |will -advise tbe tattooer. <br />MT I am not pregnant or nursing. <br />MT I am not under the influence of alcohol or drugs. <br />MT | acknowledge that infection is always possible as a result of obtaining o tattoo, particularly in the <br />event that |donot take properoa[eOfrnytattoo-|haVe-reoeiVed aftercare instructions and | agree tp <br />follow them while my tattoo is healing. I agree that any touch-up work needed, due to my own <br />negligence, will be done at my own expense. This includes sun and ultraviolet frequency damage. <br />&4T I acknowledge that a tattoo is a permanent change to my appearance and that no representations <br />have been made to me as to the ability to later change or remove my tattoo. To my knowledge, I do <br />not have physical, mental or medical impairment or disability which might affect my well being as a <br />direct or indirect result ofrnydecision to have atattoo. <br />MT | acknowledge that ifnnytattoo is asymbol, orsomething written inglanguage other than English, <br />the tattoo artist and the owner ofthis business are not responsible for what itmay mrmay not mean. <br />MT I acknowledge that if my tattoo includes text that I am responsible for the correct spelling, grammar <br />and punctuation. | have proofed the text before itisapplied esatattoo. <br />MT | acknowledge that variations incolor and design m8yexist between any tattoo as selected by me and <br />as ultimately applied to my body. | understand that ifD1Vskin color iSdark, the colors will not appear <br />aabright asthey doonlight skin. <br />MT I acknowledge the decision for obtaining my tattoo is my own free will and choice. I consent to the <br />location of the tattoo and the performance of the tattoo procedure. <br />MT ]ackDoVWedge and agree tDfollowing any and aUinstructions providedtornoregarding tha <br />maintenance ofa sanitary environment while | am being tattooed. <br />