Laserfiche WebLink
Tat to Consent Release Form <br />I acknowledge by signing this release form that No leen given the full opportunity to ask any and all questions that i might <br />have aboert'obtaining my tattoo from any artist at Iv lissa Santos Canvas Tattoo (which from hero, thmuEttout the rest of <br />form will be referred to as Canvas Tattoo). l ackno% edge that all my questions have been answered to my total <br />satisfaction_ I specifically acknowledge that i have i en advised of the facts and matters set forth below, and agree as <br />follows: <br />(please read and initial the following) <br />_I am not under the influence of drugs or a! ahol. <br />1 am at least 18 years old. <br />_ _I am free of communicable diseases. <br />1 am not pregnant. <br />_I do not have any moles, freckles, or sunburn in the arra to be tattoo( J. <br />I have looked over my design, checked spelling if applicable, and gavcn (try con.wxA to the i plication rif y <br />tativo. <br />I acknowledge that it is not reasonably possil le for the artists or anyone at Canvas Tattoo tr letcrmine why her l <br />might have an allergic reaction to dyes, pigments, or p ocesses used in my tattoo. I agree to aocept tha these risks at <br />possible. <br />_I acknowledge that infection is always poss ale as a result of obtaining a tattoo, particularly 1 do not prop -ly <br />care for my tattoo. Written instructions of proper care have been given and I recognize the absolute neLessity of folio ing <br />them <br />I acknowledge d at variations in color and ( esign may exist between tattoos as selected by me and as ultim ely <br />applied to my body. <br />_I acknowledge tt A tattoo inks, dyes and pi; menta, have not been approved by the FDA and that the health <br />concenuences of using the- �! products are unknown- <br />­11 acknowledge Oat tattoos are permanent, a id will change my appearance. <br />_- 1 acknowledge hat obtaining a tattoo is my � hoice alone and that I consent to the application of the tattoo and to <br />any actions or conduct o all artists, and anyone at Can its Tattoo that are reasonably necessary to preform the tattoo <br />procedure. The undersil ned agrees to release and forev -,r discharge and forever hod harmless Canvas Tattoo and it's artists. <br />associates, agents and, rpresentatives from any and all a lwms, damages or legal actium arising from or connected m any <br />way with my tattoo, # c procedures, and conducts used t, apply my tattoo and all tattoos applied by Canvas Tattoo artists in <br />the future. what to expect after getting your tattoo. <br />After procedure there may be some slight tenderness to the area. it is normal to see <br />some liquid for example blood/plasma and some expelled ink. After a few days the tattoo will be <br />itchy during the healing process. It is normal to witness slight scabbing as it is part of the healing <br />process. If there are any questions please contact us. <br />Please print your hill name as it appears on vour ID on the ;ne below <br />I have fully informed of the risks of tattooing, including but not limited to <br />infeciiosi, starring, difttcuitiis . detectiraL melanoma and allergic reaction to tattoo pigments -,gloves~ etc_ Having- been <br />informed of such risks. I still wish to proceed with the tattoo application and ) assu-me any and all rides that may arise fmm <br />tattooing and tattoo. <br />�monature <br />date- _ telephone # <br />Please circle any condition that may apply to you. TB, Epilepsy, Bland thinner, Scarringrl:eloid, tlTl; Asthma, <br />Eczema/Psoriasis, Gonorrhea/Syphilis, Hepatitis, Heart co-tdition, MRSA./staoh infections. Hemophilia <br />Or any other bleeding diseases Pre2nant+Nursintl. <br />Allergic region to latex, Herpes intimion at procedure sit,, Diabetes Other risk factors for bloodborne pathogens <br />Medical History. Please answer following questions. <br />When did you eat last? _ .?©o you leave; additional allertties IE metal, soaps, cosmetics, or ak;ohoie <br />Do you use any medications that might affect healing of tat oo? ----Do you. have any medical or skin conditions that <br />might affect the outcome of your tattoo? _ Have you been prescribed antibiotics prior to dental or medical <br />procedure?_._ Deo you have any Cardiac valve dis:ase? __ is there any info you feet you should provide to <br />your artiste ars you allergic to any antibiotics? Please list current medications here <br />Artist - tt>cedles _.... <br />r descripxti;on of tattoo— ­— <br />r <br />