Fillable Printable Consent to Tattoo Procedure Release and Waiver of All Claims -Wiscosin

Consent to Tattoo Procedure Release and Waiver of All Claims -Wiscosin

DEPARTMENT OF HEALTH SERVICES

Division of Public Health

F-00757 (04/2013)

STATE OF WISCONSIN

Bureau of Environmental and Occupational Health

DHS 173

(608) 266-2835

CONSENT TO TATTOO PROCEDURE

RELEASE AND WAIVER OF ALL CLAIMS

Operators are required by DHS 173.10 (2) to collect certain personally identifiable information for the purpose of determining procedural

eligibility. Completion of this form is not required by statutory reference. Services will not be provided without the completion of this

form.

I acknowledge by signing this Release that I have been given full opportunity to ask any and all questions that I

might have about obtaining a tattoo and that all my questions have been answered to my full satisfaction. I

specifically acknowledge that I have been advised of the facts and matters set forth below and I agree as

follows:

1) If I have diabetes, epilepsy, hepatitis, hemophilia, HIV-AIDS or any other communicable disease, heart

condition or I take medication that thins the blood, I have advised my tattooer. I am not pregnant or

nursing. I am not under the influence of alcohol or drugs.

2) I do not have medical skin conditions such as, but not limited to: acne, scarring (keloid), eczema,

psoriasis, freckles, moles or sunburn in the area to be tattooed that may interfere with my tattoo.

3) I acknowledge it is not reasonably possible for the employees of ________________________ to

determine if 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.

4) 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 suggestions and agree to care for my

tattoo to the best of my ability.

5) I 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 is dark, the colors will not appear as bright as

they do on light skin. I understand that a tattoo is a work of art and minor imperfections are likely.

6) I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering

procedures, it may result in adverse changes to my tattoo.

7) I acknowledge that a tattoo is a 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

any physical, mental or medical impairment or disability that might affect my well being as a direct or

indirect result of my decision to have a tattoo.

8) I have truthfully represented to _______________________________ that I am at least 18 years of age

and that obtaining a tattoo is by my choice alone.

Therefore, I request the application of a tattoo. I agree to release and forever discharge and hold harmless

____________________________, and all employees from any and all claims, damages or legal actions arising

from or connected in any way to my tattoo or the procedure and conduct used in the application of my tattoo.

Name – Print legibly

SIGNATURE - Patron

Address City State Zip

Date of Birth

Age today

Today’s Date

Email Address

Name of Practitioner (print legibly)

SIGNATURE - Practitioner