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12 Monkeys Tattoo ® Consent & Waiver I __ being eighteen (18)years of age or older, hereby consent to a,tattoo to be conducted by"12 Monkeys Tattoos" or an agent or employee of the same as follows: Tattoo description: Location: Artist: Price: I understand "12 Monkeys Tattoos" has taken appropriate steps to ensure sanitary conditions for said tattoo. More specifically, I have initialed the areas below indicating: Only single use sterile needles are used,and are disposed of in a medical sharps container after every tattoo. The pigments and supplies that will be used in the application of the tattoo are single use per customer. I understand that inks are not FDA approved and health consequences are unknown. I have received and read the aftercare information,and understand the steps necessary for safe, sanitary maintenance. I acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions which I might have and that all of my questions have been answered to my full satisfaction. I specifically acknowledge I have been advised of the matter set forth below and agree as follows: 1. 1 am not pregnant or nursing. I don't have epilepsy or hemophilia. I do not suffer from any heart conditions. I do not take any blood thinning medications. 2. If I suffer from hepatitis or any other communicable disease, 1 have informed the tattooist of this fact and have been advised by my doctor of any medications and procedures necessary to promote the satisfactory healing of my tattoo. 3. 1 do not suffer from medical or skin conditions such as but not limited to: keloiding, hypertrophic scarring, or psoriasis at the site of the tattoo,or any open wounds or lesions at the site of the tattoo. 4. 1 have advised the tattoo artist of any allergies to metals,latex,soaps,cleansers, or medications. I acknowledge it is not reasonably possible for the tattoo artist to determine whether I might have an allergic reaction to the process involved in the tattoo and further acknowledge that such a reaction is possible. 5. 1 have truthfully represented to the tattoo artist that I am over the age of 18 years. I am not under the influence of drugs or alcohol. To my knowledge I do not have any 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 done at this time. 7. 1 acknowledge that obtaining a tattoo is my choice along and will result in a change to my appearance, and that no representation has been made to me as to the ability to later restore the skin involved in this tattoo to its pre-tattooed condition. I acknowledge that my tattoo is permanent. 8. 1 acknowledge that infection is always possible as a result of obtaining a tattoo and agree to follow all instructions concerning the care of my tattoo while it is healing. services for I agree to pay the above price in full at the time services are rendered. In consideration for the tattoo se cis per mid at my request, I release"12 Monkeys Tattoos" and any of its employees, agents, contractors, or assigns thereof,from all claims and rights of actions of any kind which I now have or which may accrue, arising out of the above described tattoo services and related activities, including but not limited to:claims of personal injury, property damage and other losses incurred as a result(direct or indirect) of said tattoo services, including injuries, damages and losses which are presently known as well as those which may or ie discovered in the future. I further waive all of said claims and rights of action. I have read this document and tn=procedure and any potential risks thereof and agree to all of its contents. I represent that all information provided _. .. e_n chis form and verbally is true and accurate. DATE OF BIRTH J � fiDDRESS: PHONE( ) DRIVERS LICENSE# STATE EMAIL: (if you wish to receive upcoming event information) I TS SIGNATURE CUSTQMER/CLEN 5 GNARE DATE U