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Tattoo Consent Release Form I acknowledge by signing this release form dint rve been given the full opportunity to ask any and all questions that I might have abonn obtaining my tattoo from any artist at Melissa Santos Canvas Tattoo (which from here, throughout the rest of form will be referred to as Canvas Tattoo). I acknowledge that all my questions have been answered to my total satisfaction I specifically acknowledge that I have been advised of the facts and matters set forth below, and agree as follows: (please read and initial the following) I am not under the influence of drugs or alcohol. _. _I am at least 18 years old. _I am free of communicable diseases - am not pregnant. --__ I do not have any moles, freckles, or sunburn in the area to be tattoos I I have looked over my design, checked spelling if applicable, and given my consent to the application of my tattoo. I acknowledge that it is not reasonably possible for the artists or anyone at Canvas Tattoo to determine whether 1 might have an allergic reaction to dyes, pigments, or processes used in my tattoo. I agree to accept that these risks are possible. _ I acknowledge that infection is always possible as a result of obtaining a tattoo, particularly if I do not properly care for my tattoo. Written instructions of proper care have been given and I recognize the absolute necessity of following them I acknowledge that variations in color and design may exist between tattoos as selected by me and as ultimately apnlied to my body. _I acknowledge that tattoo inks, dyes and pigments, have not been approved by the FDA and that the health consequences of using these products are ankriown. _ __I acknowledge that tattoos are permanent and will change my appearance. _I acknowledge that obtainers a tattoo is my choice alone and that I consent to the application of the tattoo and to any actions or conduct of all artists, and anyone at Canvas Tattoo that are reasonably necessary to preform the tattoo procedure. The undersigned agrees to release and forever discharge and forever hod harmless Canvas Tattoo and it's artists, associates, agents and represerrFetives from any and all claims, damages or legal actions arising from or connected in any way with my tattoo, the procedures, and conducts used to apply my tattoo and all tattoos applied by Canvas Tattoo artists in the futuue. Please print your full name as it appears on your ID on the line below I _` have fully informed of the risks of tattooing, including but not limited to infection, scarring, difficulties in detecting melanoma, and allergic reaction to tattoo pigments, gloves, ctc. Having been informed of such risks, I still wi* to proceed with the tattoo application and I assume any and all ricks that may arise from tattooing and tattoo. ____-_ sipnature date telephone;4 Please circle any condition that may apply to you. TB, Epilepsy, Blood fiinner, Scarring/Keloid, MV, Asthma Fezerna/Psoriasis, Gonorrhea/Syphilis, Hepatitis, Heart condition, MRSA/staph infections, Hemophilia, Pregnant/Nursing, Allergic reaction to latex, Herpes infection at procedure site, Diabetes Other risk factors for bloodborne pathogens Medical History. Please answer following questions. When did you eat last? jDo you have additional allergies lE metal, soaps, cosmetics, or alcohol'? Do you sex, any rnedicafiom that might affect healing of tattoo? _ Do you have any medical or skin condition—s that might affect the outcome of your tattoo? _ Have you been rrrescribed antibiotics prior to dental or medical procedure? ._ _ -Do you have any Cardiac valve disease? _ is there any info you feel you should provide to Your artist? ____are you allergic to any antibiotics?_ _ _ Please list current medications here Artist needles lot# - -------- - descnption$---