Tattoo & Piercing Standard Release Form
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1723 W. Lumsden Road
Brandon, FL 33511
813.654.8288
TATTOO & PIERCING STANDARD RELEASE FORM
Name:____________________________________________
Date:_____/_____/_____
Address:________________________________ City:_________________ State:_____ Zip:_________
Email:__________________________________________ Phone: (___)__________________________
Date of Birth:_____/_____/_____
Age:_______
Race:_____________
Sex:_________
Emergency Contact:_________________________________
Phone: (___)_____________________
* In case of an emergency, client acknowledges that they wish to be taken to Brandon Regional Hospital.
_____ Initials
Bleeding Disorders: ____ Yes ____ No
If Yes, List:_____________________________________
Allergies/Skin Conditions:_________________________________________________________________
I acknowledge that I am at least 18 years old. I do not have a heart condition. I am not diabetic. I haven’t had hepatitis within the last year. I am not
a hemophiliac (bleeder). I do not have epilepsy. I am not under the influence of drugs or alcohol. To my knowledge, I do not have a physical,
mental, or medical impairment or disability, which might affect my well-being as a direct or indirect result of my decision to have any
tattoo/piercing done at this time. Being of sound mind and body, I hereby release any and all persons representing Legacy Tattoo from all
responsibility. I accept any and all responsibility for myself, for any and all consequences that might arise from my decision to have any
tattoo/piercing done by Legacy Tattoo. I agree not to bring suit against Legacy Tattoo or any of its owners/employees, in connection with any and
all damages, claims, demands, rights, and causes of action of whatever kind of nature, based upon injuries or property damage to, or death of
myself, or any other person arising from my decision to have a tattoo/piercing done at this time, whether or not caused by any negligence of
Legacy Tattoo or any person representing Legacy Tattoo. I agree to pay any and all damages and injuries to any and all persons and property
belonging to Legacy Tattoo, or any other persons to whom Legacy Tattoo may become liable contractually or by operation of law, caused by, or
resulting from my decision to have any tattoo/piercing done by Legacy Tattoo. I agree to pay the reasonable attorney’s fees and costs arising from
any legal action against Legacy Tattoo bought by myself, my agents, or assigns. I agree to leave the premises of Legacy Tattoo, or any other
establishment where Legacy Tattoo is engaged in business, promptly upon request, for any reason whatsoever, by any agent or employee of
Legacy Tattoo. I agree that those waivers also pertain to and are designed to protect any and all establishments where Legacy Tattoo conducts
business. I represent and warrant to Legacy Tattoo that the above information is true and correct. I have advised the Piercer/Tattoo Artist of any
allergies to metals, latex gloves, soaps, and medications. I acknowledge it is not reasonably possible for the Piercer/Tattoo Artist to determine
whether I might have an allergic reaction to the piercing/tattoo or process involved in the piercing/tattoo and further acknowledge that such
reaction is possible. I have had the aftercare instructions explained to me. I understand all the aftercare instructions as they were explained. I have
been given a copy of my aftercare instructions. I agree to follow all instructions concerning the care of my tattoo/piercing while it is healing. I
acknowledge infection is always possible as a result of obtaining a piercing/tattoo. I agree that any touch-up work needed, due to my own
negligence, will be done at my own expense. I understand that if my skin is dark, the colors may not appear as bright as they do on lighter skin. I
realize that my tattoo/piercing is being done in a sterile environment with sterile instruments, sterilized in an Autoclave. I accept any and all
responsibility myself for any consequences that might arise from my decision to have any tattoo/piercing work done at Legacy Tattoo.
Signature:_______________________________________________________
Date:_____________
Parent/Guardian Signature:________________________________________ Date:_____________
Type of Identification Produced:________________________________________________________
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