Name * First Name Last Name Email * Phone * Country (###) ### #### Date of Birth * MM DD YYYY Emergency Contact * Country (###) ### #### Type of Body Art Procedure * Tattoo Piercing Date of Procedure * MM DD YYYY Name of Assigned Artist * I acknowledge by signing this release form that I have been given a full opportunity to ask any questions that I might have about obtaining Body Art and/or Piercing Services. All of my questions have been answered to my full satisfaction. I specifically acknowledge that I have been advised of the facts set forth and I agree as follows * I agree and understand How long has it been since you last ate? * Do you have any additional allergies such as to metals, soaps, cosmetics, or alcohol? * Do you have diabetes epilepsy, hepatitis, hemophilia, HIV-AIDS, or any other communicable disease, or heart condition or take medication that thins the blood? * I am not pregnant or nursing. I am not under the influence of alcohol or drugs. * Agree Disagree Do you have any other medical or skin conditions that might affect the outcome of this procedure? * I have been fully informed of the risks of body art including but not limited to infection, scarring, and allergic reactions to items associated with body art procedures. The technician will not perform the body art procedure if you fail to complete or sign this form. Further, the technician may decline to perform a body art procedure if the client has any identified health conditions. Having been informed of the potential risks associated with this body art procedure, I still wish to proceed with the body art application and I assume any/all risks that may arise from body art. * I agree and understand Thank you!
