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CENT TO TATTOO F \.._ CON NAME Date D.O.B. LICENSE NO. ADDRESS CITY STATE ZIP HOME PH. I acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions which I might have about the obtaining of a tattoo and that all of my questions have been answered to my full satisfaction. I specifically acknowledge I have been advised of the facts and matters set forth below and I agree as follows: • If I have any condition that might affect the healing of this tattoo,I will advise my tattooer. I am not pregnant or nursing. I am not under the influence of alcohol or drugs. I do not have medical or skin conditions such as but not limited to:acne,scarring(Keloid)eczema,psoriasis,freckles, moles,sunburn or herpes in the area to be tattooed that may interfere with said tattoo. If I have any type of infection or rash anywhere on my body,I will advise my tattooer. • Do you have any history of hemophilia or other bleeding disorder,Diabetes or any heart conditions such as cardiac valve disease? If so please let the artist know. • I have advised the tattooer of any allergies to metals, latex gloves, soaps and medications. I acknowledge it is not reasonably possible for the tattooer to determine whether I might have an allergic reaction to the piercing or processes involved in the tattoo and further acknowledge that such a reaction is possible. • I acknowledge it is not reasonably possible for the representatives and employees of this tattoo shop to determine whether I might have an allergic reaction to the pigments or processes used in my tattoo,and I agree to accept the risk that such a reaction is possible. • I acknowledge that infection is always possible as a result of the obtaining of a tattoo,particularly in the event that I do not take proper care of my tattoo. I have received aftercare instructions and I agree to follow them while my tattoo is healing. I agree that any touch-up work needed,due to my own negligence,will be done at my own expense. • I realize that variations in color and design may exist between any tattoo as selected by me and as ultimately applied to my body. I understand that if my skin color is dark,the colors will not appear as bright as they do on light skin. • I understand that if I have any skin treatments,laser hair removal,plastic surgery or other skin altering procedures,it may result in adverse changes to my tattoo. • I acknowledge that a tattoo is a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove my tattoo. To my knowledge, I do not have a physical, mental or medical impairment or disability which might affect my well being as a direct or indirect result of my decision to have a tattoo. • Do you have any allergic to any antibiotics? • Do you have a history of medications use or is currently using medication,including prescribed antibiotics prior to dental surgical procedures please list: • Do you have Herpes,HIV,Hepatitis B,Hepatitis C or and other blood home pathogens? ® I acknowledge I am over the age of eighteen and that I have truthfully represented to my tattooer that the obtaining of a tattoo is by my choice alone. I consent to the application of the tattoo and to any actions or conduct of the representatives and employees of the tattoo shop reasonably necessary to perform the tattoo procedure. Tattoo inks,dyes and Pigments have not been approved by the federal food and drug adindnistradon and that the health consequences of using these products are unknown Signature: DATE TATTOOER: DATE PLACMENT OF TATTOO Description of Tattoo Price: ALL DEPOSITS ARE NON-REFUNDABLE