Fillable Printable Permanent Cosmetics/Tattoo Consent Release Form

Permanent Cosmetics/Tattoo Consent Release Form

PERMANENT COSMETICS/TAT TOO CONSENT RELEASE FO RM

W:\Data\EH-PROGRAMS & PROJECTS\BODY ART\FORMS\WORD DOCS\SAMPLE FORM - PERMANENT COSMETICS TATTOO CONSENT RELEASE FORM 3 11 14.doc SAMPLE FORM

I acknowl edge by signing this release f orm that I have been given the full oppo rtunity to ask any and all qu est ions I might have

about obtaining a tattoo from ____ __________. I acknowledge that al l m y questions have been answered to my ful l and total

satisfa ct i on. I specifically ackno wledge that I have been advised of the fact s and matters set forth belo w, and I agree as follows:

I am not under the influence of alcohol or drugs.

I do not have acne, frec kles, moles, or sunburn in the area to be tattooed that mi ght be agitated by the tattoo process

(healing ex cluded).

I have looked over my design, checked the spell i ng i f applicable, and give my full consent to the appl ication of my

tattoo.

I acknowl edge that I am not pregnant.

I acknowl edge that I am free of communi cable disease.

I acknowl edge that I have truthfully represented to the associates, agents and repres entatives of _____________ that

I am over ei ghteen (18) y ears of age.

I acknowl edge it is not reasonably possible for the associates, agents and repre sent atives of ________________ to

determine whether I m i ght have an alle rgic reactio n to the dyes, pigments, or processes used in my tattoo and I agree

to accept that such risk s are possible.

I acknowl edge that infection is alw ays possible as a result of obtaining a tat too particula rly in that event that I do not

take prope r care of my t attoo, and I have been advised of the signs and sym ptoms of infection that indicate a need to

seek medical care.

I acknowl edge receipt of written instructions advising me of prop er care of my tattoo and recognize the abs olute

necessity of following those written instructions. All questions about t he body art procedure have been answered to m y

satisfaction.

I acknowl edge that v ariations in color a nd design may exist bet ween any tattoos as selected by me and as ul timately

applied t o m y body.

I acknowl edge that t attooing is a permanent change t o my appearance and that no representations have been made to

me as to the ability to later change, al ter or remove my tattoo.

I acknowl edge that t he obtaining of my tattoo is my choice alone and I consent to the appli cation of the tattoo and to

any action s or conduct of the associates, agents or representat i ves of _________________ that are reasonabl e

necessary to perform the tattoo procedure.

I agree to release and for ever discha rge and forever hold harmless ______ ______________________and its

associates, agents off icers and sh areholders f rom any and all claims, damages, or legal act i ons arising from or

connected in any way with my tattoo or the procedures and conduct used t o apply my tattoo and any and all tattoos

applied by ______________________ and its associates, agents and repre sentatives in the future.

I acknowl edge that t attoo inks, dyes an d pigm ents have not been approv ed by the federal Fo od and Drug

Administration and the health consequences of using these products are unkno wn.

I acknowl edge that t here is a chance I might feel lightheaded, diz zy during or after being t attooed. I agree to

immediately notify the practitioner i n the event I feel lightheaded, dizzy and/or faint before, during or after the

procedure.

I agree to f ol l ow all i nstructions concerni ng the care of m y tattoo, and that any touch-ups needed bec ause of my own

negligenc e will be done at my own expense.

I, _______________________________________ _______have been fully i nformed of the ris ks of tattooin g i ncluding but not

limited to infection, scarring, di fficulties i n detecting mel anoma, and all ergic reacti ons t o tattoo pigment , latex gloves, and

antibiotics. Havi ng been inform ed of the pot ential risks associated wit h getting a tattoo, I still wish to proceed with tattoo

application and I assume any and all risks that may arise from tat tooing.

If single-use presteril ized equipm ent is used please provide L ot/ID numb er.

Artist:

Lot/ID #:

Signature:

Date:

Procedure description: