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CONSENT TO TATTOO PROCEDURE D.O.B. ADDRESS CITY STATE_ZIP HOME PH, I acknowledge by signing this agnx I I Wat(have been given the tall opportunity in ask any Rod NI questions which I might have about the obtaining of a tattoo and that all of my questions have been onmvered to my full satisfaction. I specifically acknowledge I have been advised of the facts and matters set forth below end 1 agree as follows: • If have any condition that might affect the healing of this tattoo, I will advise my tattimer. lamnotprcgnonterrursing. I am not under the influence of alcohol or drugs. • I do not have medical or skin conditions such as but not limited to: acne, sculling (Keloid) eczema, psoriasis, freckles, moles, sunburn or herpies in the area to he tattooed that may interfere with said tattoo. If I have any type of infection or rush ammlic on my body, l will advise my tattooer, • Do you haves leaso loryofheistknoia or other bleWingdisorder, Diabetes or onyheart rnndidons such as cardiacvalve disease? If so please let We artist know, • 1 have advised the tattooer of arty allergies to metals, latex gloves, soaps and medications. I acknowledge it is not reasonably possible for the laltoxr to determine whether I might have an allergic reaction to the 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 processes used in my tattoo: and I agree to accept the risk that such a reaction is possible. • 1 acknowledge that infection is always possitilc as a result of the obtaining ofn tattoo, particularly in the event That 1 do not take proper care of my tattoo, f have received aftercare instructions and I agree to follow them while my tattoo is healing I agree that any torch -up work needed, due to my own negligence, will be done at my own expense. • I realizes 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 any skin color is dark, the colors will not appear as bright as they do on light skin. • lunderstood that ifl have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my tattoo. , • I acknowledge (hot a tattoo .isa permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove my tattoo. To my knowledge, I do not have a physical, mental or medical impairment or disability which might affect my well-being as a direct or indirect mull of my decision to have a tattoo. • Are you allergic to any enli-biotics?: • Do you have a history of medications use or is currently using medication, including prescribed antibiotics prior to dental surgical procedures? Please list: • Do you have FIIV, Hepatitis B, Hepatitis C or other blood home pathogens?: • 1 acknowledge I am over the ago of eighteen and that I have WtlSully represented to my tattooer Ilett the attaining of a tattoo is bymy choice alone. fcanscnl to the application of the tattoo and to mty actions or conduct ofthc representatives and'employees of the tattoo shop reasonably necessary to perform the tattoo pmM1111m. • I understand Tattoo inks, dyes Mid Pigments huve not been approved by the federal food and drug administration and that the health consequences of using these products are unknown PLACMENT OP TATTOO: Description of Tattoo: Box NO: Needle NO: De osil: & ALL DEPOSITS ARE NON REFUNDABLE