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INFORMED CONSENT TO BODY ART <br /> PLEASE READ AND CHECK THE BOXES WHEN YOU ARE CERTAIN YOU UNDERSTAND THE <br /> IMPLICATIONS OF SIGNING <br /> In Consideration of receiving BODY ART from , the practitioner <br /> at UPTOWN INK , (together with its employees, apprentices, and agents.) <br /> I confirm the following by initialing each applicable item: <br /> ( Client's Name ) <br /> All questions about the body art procedure have been answered to my full satisfaction, and 1 have been <br /> given written aftercare instructions for the procedure I am about to receive. <br /> I have looked over my design,checked spelling,and give my full consent to the application of my tattoo. <br /> 1 do not have acne,freckles, moles, or sunburn in the area to be tattooed that might be agitated by the <br /> tattoo process (healing excluded). <br /> I understand that variations in color and design may exist between any tattoo as selected by me and as <br /> ultimately applied to my body. <br /> 1 understand that tattooing is permanent and cannot be changed altered or removed,and that if 1 choose <br /> to have it removed, it may be expensive and leave scars. <br /> I am the person on the legal ID presented as proof that I am at least 18 years of age. <br /> I am not under the influence of alcohol or drugs and that I am voluntarily submitting to be tattooed <br /> without duress or coercion. <br /> 1 understand there is a possibility of an allergic reaction to dyes, pigments or processes used in my <br /> tattoo, and I agree to accept that such risks are possible. <br /> I acknowledge that infection is always possible as a result of obtaining a tattoo particularly in the event <br /> that 1 do not take proper care of my tattoo. <br /> I agree to follow all instructions concerning the care of my tattoo, and that any touch-ups needed due to <br /> my own negligence will be done at my own expense. <br /> I understand that there is a chance I might feel lightheaded,or dizzy during or after being tattooed. I will <br /> immediately notify the artist in the event that any of this occurs. <br /> I agree to release and forever discharge and forever hold harmless UPTOWN INK and its associates, <br /> agents, and officers from any and all claims,damages,or legal actions arising from or connected in any <br /> way with my tattoo or the procedures and conduct used to apply my tattoo and any and all tattoos applied <br /> by UPTOWN INK and its associates,agents and representatives in the future. <br /> I, have been fully informed of the risks of tattooing <br /> including but not limited to infection, scarring, difficulties in detecting melanoma, and allergic reactions to tattoo <br /> pigment, latex gloves, and antibiotics. Having been informed of the potential risks associated with getting a <br /> tattoo, I still wish to proceed with tattoo application and I assume any and all risks that may arise from tattooing. <br /> Signed Date <br /> ARTIST USE ONLY: TOTAL= $ SS <br /> Tube Type Batch# Date DEPOSIT $ <br /> DISPOSABLE 3R 5R 7R 11M 13M 15M Other TOTAL= $ <br />