Tattoo Consent And Release Form - Release Forms
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1TATTOO CONSENT AND RELEASE FORM
Name of Patron)________
Name of Operator)_______________
I, (
, hereby give consent to (
of
Name of Establishment)______________
(
to perform a tattoo/body pierce, and in consideration of doing
Name of Operator) ___________
Name of Establishment) _____________
so, I hereby release (
and (
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.
Name of Establishment
I fully understand that any employee of (
) _____________, 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
Name of Establishment
reversing these changes have been made or implied by (
) _____________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 _________________________________
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