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CONCENT TO TATTOO NAME: DATE: D.O.B: LICENCE# ADDRESS: CITY STATE: ZIP: PHONE: I acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions which I 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: • If I have any conditions that might affect the healing of this tattoo, I will advise my tattooer. I 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. • I acknowledge that infection is always possible as a result of obtaining a tattoo,particularly in the event that I do not take proper care of my tattoo. I have received aftercare instructions and I agree to follow them while my tattoo is healing. I 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. 1 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 I 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 bome 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: