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''HE PIRATES LOUNGE TAT-TOO PARLOR <br /> 2714 COURY CLUB BLVD SUITE F,STOCKTON, CA 064 <br /> CONSENT OF APPLICATION OF TATTOO AND RELEASE AND WAIVER OF ALL CLAIMS <br /> DATE:—_/___/ <br /> I acknowledge by signing this document that I have been given full opportunity to ask any and all <br /> questions which I might have about obtaining of a tattoo. I specifically acknowledge that I have been advised of the facts and matters set <br /> forth below,and I agree as follows: <br /> —1 acknowledge that I am at least 28 years of age. <br /> —1 acknowledge that I am not pregnant or nursing. <br /> —1 acknowledge that I am free from Jaundice,Hepatitis or other communicable diseases. <br /> —i acknowledge that I am not underthe influence of drugs or alcohol and I am voluntarily submitting to be tattooed without duress or <br /> coercion. <br /> —1 acknowledge receipt of written Instructions advising me of proper care of the tattoo. <br /> —1 acknowledge that the tattoo should be considered permanent:that it can only be removed by surgical procedure and that any effective <br /> removal may leave permanent scarring or disfigurement. <br /> —1 acknowledge that it is not reasonable possible for the representatives of The Pirates Lounge Tattoo Studio,to determine whether I <br /> might have an allergic reaction to the dyes,pigments and/or processes used in the execution of the tattoo and I agree to accept the risk that <br /> such a reaction Is possible. <br /> —1 acknowledge that tattoo inks are not FDA approved and health consequences are unknown. <br /> —1 acknowledge that with tattoos there is always a possibility of getting an infection. <br /> —Your tattoo should heal in 2 weeks. Refer to provided aftercare sheet for proper care instructions. Expect redness and soreness for the <br /> first 1-4 days. <br /> _j agree to release and forever discharge and hold harmless The Pirates Lounge Tattoo Studio,and it's contractors,employees,agents <br /> and/or representatives from any and all claims,damages or legal actions arising from or connected in any way with the tattoo or the <br /> procedure and/or conduct used to apply said tattoo. <br /> —--—--——--------- <br /> NAME: DOB: <br /> ADDRESS: —CITY,STATE,ZIP: <br /> TELEPHONE,(_) TATTOO DESIGN: <br /> LOCATION: COST: ARTIST: <br /> SIGNATURE: <br />