Fillable Printable Tattoo Liabilty Waiver Form - Wisconsin

Tattoo Liabilty Waiver Form - Wisconsin

CONSENT AND RELEASE FORM

SAMPLE

I, (

Name of Patron)________

, hereby give consent to (

Name of Operator)_______________

(

Name of Establishment)______________

to perform a tattoo/body pierce, and in consideration of doing

so, I hereby release (

Name of Operator) ___________

and (

Name of Establishment) _____________

from

all manner of liabilities, claims, actions, and demands in law, or in equity, which I or my heirs might now or

hereafter by reason of complying with my request of a tattoo or body piercing.

I fully understand that any employee of (

Name of Establishment

) _____________, when performing a

tattoo or body piercing, does not act in the capacity as a medical professional. The suggestions made by

any employee or agent of (

Name of Establishment

) ___________ are just suggestions. They are not to be

construed as, or substituted for advice from a medical professional. I understand that the tattoo or body

piercing will be performed using appropriate techniques, instruments, and pigments. I also understand that

infections can occur due to lack of proper hygiene and/or pigment sensitivities. To ensure proper healing of

my tattoo or body piercing, I agree to follow the written and verbal aftercare instructions that will be

provided, until healing is complete. I understand that a tattoo or body piercing may take several weeks to

heal properly.

I understand that I am making a permanent change to my body, and no claims about the possibility of

reversing these changes have been made or implied by (

Name of Establishment

) _____________or any of

its employees or agents.

Please Answer the Following Questions:

*Answering "yes" to any of these questions does not necessarily preclude the person

from receiving a tattoo or piercing.

YES NO

• Has a physician told you that you have hepatitis? ____ ____

• Have you been jaundice (yellowing of skin or eyes) in the previous 10 days? ___ ____

• Are you prone to fainting? ____ ____

• Do you have diabetes? ____ ____

• Do you have difficulty-stopping bleeding? ____ ____

• Do you take a blood thinner? ____ ____

• Do you have heart related problems? ____ ____

• Do you have high blood pressure? ____ ____

• Do you have any known allergies? ____ ____

If so, please list them ___________________________________________

__________________________________________

• Have you consumed any alcoholic beverages within the last 8 hours? ____ ____

• Have you consumed any food within the last 2 hours? ____ ____

• Have you consumed any anticoagulants (aspirin, ibuprofen, etc.)

in the last 24 hours? ____ ____

• Are you pregnant? ____ ____

• Do you have any other conditions that might affect the healing of this

tattoo/body piercing? ____ ____

I have read this release form and confirm that all the information I have given is correct. I

understand that this is a release form and I agree to be legally bound by it.

I certify that I am over __________ years of age. Date of Birth ________________

Your Name___________________________ Telephone ( ) _____________________________

Address _____________________________ City State Zip _________________________________

Signature ____________________________Today's Date _________________________________