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NAME: DATE: D.O.B: LICENCE# ADDRESS: CITY STATE: ZIP: PHONE: I acknowledge by signing this agreement that 1 have been given the full opportunity to ask any and all questions which 1 might have about obtaining of a tattoo and that all my questions have been answered to my full satisfaction. 1 specifically acknowledge I have been advised of the facts and matters set forth below and agree as follows(Notice that tattoo inks, Dyes &pigments have not been approved by the FDA&consequences of using these products are unknown): • If I have any conditions that might affect the healing of this tattoo, I will advise my tattooer.1 am not pregnant or nursing. I am not under the influence of alcohol or drugs. I do not have a medical or skin conditions such as but not limited to:acne,scarring,(Keloid)eczema,psoriasis,freckles,moles, sunburn or herpes in the area to be tattooed that may interfere with said tattoo. If I have any type of infection or rash anywhere on my body.I will advise my tattooer • Do you have any history of hemophilia or other bleeding disorder,Diabetes or any heart conditions such as cardiac valve decease if so please let the artist know • I have advised the tattooer of any allergies to metals,latex gloves,soaps and medications. I acknowledge it is not reasonably possible for the tattooer to determine whether I might have an allergic reaction to piercing or processes involved in the tattoo and further acknowledge that such a reaction is possible. • I acknowledge it is not reasonably possible for the representatives and employees of this tattoo shop to determine whether I might have an allergic reaction to the pigments or process used in my tattoo and agree to accept do you have a history of the risk that such a reaction is possible. • 1 acknowledge that infection is always possible as a result of obtaining a tattoo,particularly in the event that 1 do not take proper care of my tattoo. 1 have received aftercare instructions and I agree to follow them while my tattoo is healing. 1 agree to follow that any touch up work needed due to my own negligence will be done on my own expense. • 1 realize that variations in color and design may exist between any tattoo as selected by me and as ultimately applied to my body. I understand that if my skin color is dark,the colors will not appear as bight as they do on light skin • I understand that if 1 have any skin treatments,laser hair removal,plastic surgery or any other skin altering procedures,it may result in adverse changes to my tattoo. • I acknowledge that a tattoo is a permanent change to my appearance. I do not have a physical,mental or medical impairment or disability which may effect my well being as direct or indirect result of my decision to have a tattoo. • Do you have any allergy to any antibiotics? • Do you have history of medications or currently using medication,prescribed prior to any surgical procedures is so please list: • Do you have HIV,Hepatitis C or/and other blood borne pathogens? I acknowledge I am over the age of 18 and that I have trustfully represented to my tattooer that obtaining of a tattoo is by my choice alone. 1 consent to the application of the tattoo and to any actions or conducts of the representatives&employees CLIENT SIGNATURE DATE: REMARK: PLACMENT: ARTIST: