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III\► IC ! ,�,,� ►�1 18 East I I street, Suite 8 Tracy, CA 9537b (209)774-9934 I hereby initial to waive &release In Bloom, for any and all Liabilities and therefore agree not to sue for any or all liabilities, Including any personal injury, or claim of any kind which here after occurring to me as a result of participation in any tattoo, permanent cosmetic makeup or body piercing by virtue of sections 1542 of the California Civil Code. This rule applies to the following persons and entities those that may work written and or printed media advertisements. In addition to this release, I agree not to hold the persons and entities mentioned above responsible for any and all liabilities or claims made by other individuals as a result of my actions during and after any Tattoo or Body Piercing procedure or Service. I have read this release form and fully understand the content of this form. I hereby certify with my Initials that I am physically fit and that I feel sufficient to have this Tattoo or Body piercing service performed. I do not have any communicable disease such as AIDS/HIV, Hepatitis B. Hepatitis C, or Tuberculosis. In this release I am certifying that I am not pregnant, or under the influence of any substance Including alcohol. I am not diabetic or if I am I have informed the Tattoo Artist or Body Modifier of this fact. I acknowledge that there is a nonrefundable (permanent makeup or tattoo) non transferrable minimum deposit of $50 required for all service appointments. I have read and understand this release without a question and release In Bloom any/all reliabilities, I declare under penalty of perjury that the information I have provided is true and correct. Also, when I sign the guardian section of the release form, I declare under penalty o perjury that I am the true guardian of the minor and will not hold In Bloom accountable in ANY shape or form. Parental consent for piercings only. Tattoos are for 18 and older adults only. I hereby certify with my initials that I have been fully informed of the inherent risks, associated with getting a tattoo. I fully understand these risks can lead to injury, including but not. limited to infection, scarring, difficulties in detecting melanoma and allergic reaction to tattoo pigments and or soap. Having been informed of the potential risks associated with getting a tattoo, I still wish to proceed with the tattoo application, and I freely accept and expressively assume any and all risks that may arise from tattooing. I hereby certify with my initials that I understand that a tattoo is a permanent change to my appearance and can only be removed by laser or surgical means. _ Date: Name: _ ID: Age: City: Email: Signature: Artist: D:0.8 I / Phone: Guardian Signature: State: _Zip Code: Piercing:_ Piercing Service: ID CHECKED Present Jewelry Cost: $_ Tattoo Cost: $_ Tattoo Deposit: $_ Please have /D