Name *

First Name

Last Name

Phone *

Country

(###)

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Birthdate *

MM

DD

YYYY

I am eighteen or older and can legally be tattooed in the state of Pennsylvania. I have legal proof of identification and will provide a photo upload of my ID at the end of this form. *

Yes

No

Today's date *

MM

DD

YYYY

I am aware of the risks associated with getting a tattoo. I fully understand that these risks, known and unknown, can lead to injury including but not limited to: infection, scarring, difficulties in the detection of melanoma and allergic reactions to tattoo pigment, aftercare products and/or soap. Having been informed of the potential risks associated with getting a tattoo, I wish to proceed with the tattoo procedure and application and freely accept and assume any and all risks that may arise from the procedure. *

Yes

No

If I have diabetes, epilepsy, hepatitis, hemophilia, HIV-AIDS or any other communicable disease, heart condition or take medicine which thins the blood I have advised my tattooer. Similarly, if I have medical or 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, I have advised my tattooer. *

Yes

No

To my knowledge, I am not impaired in any way (physically, medically, or mentally) that might affect my well being as a direct or indirect result of my decision to get tattooed. *

Yes

No

I am not pregnant or nursing. *

I am not pregnant or nursing

I am pregnant or nursing

I understand it is not realistically possible for the owner(s)/employee(s) of this tattoo shop to determine whether 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. *

Yes

No

I am voluntarily choosing to be tattooed without duress or coercion. I am not under the influence of alcohol or drugs. I am here of my own accord and of clear mind to consent to this tattoo. *

Yes

No

I have approved the artwork/concept, sizing, placement, and color palette of my tattoo. *

Yes

No

Variations in color and design may exist between the tattoo art I have selected and the actual tattoo when it is applied to my body. I also understand that over time, the colors and the clarity of my tattoo may fade due to unprotected exposure to the sun and the naturally occurring dispersion of pigment under the skin. *

Yes

No

If my tattoo contains any words or lettering, I have double checked the spelling and have given my approval. *

Yes

No

I will follow my artist's aftercare instructions while my tattoo is healing. I acknowledge that it is possible that the tattoo can become infected, particularly if I do not follow the instructions given to me. *

Yes

No

I understand that despite having bloodborne pathogens training and licensing, a tattoo artist is not a medical professional. Any suggestions made to me are not to be construed as or substituted for advice from a medical professional. *

Yes

No

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. *

Yes

No

My artist has given me the full opportunity to ask any question(s) about the procedure and application of my tattoo and all of my questions have been answered to my satisfaction. *

Yes

No

I release the right to any photographs taken of me and the tattoo and give consent in advance to their reproduction in print or electronic form. (For assurance, if your answer is no, please confirm with the artist to not take any pictures of you and your completed tattoo). *

Yes

No

I understand that the tattoo studio has a no refund policy on tattoos and/or retail sales. *

Yes

No

I have been given adequate opportunity to read and understand this form and grasp that I am signing a legal contract waiving certain rights to recover damages against the tattoo studio. *

Yes

No