PERMANENT COSMETICS – TATTOO & PIERCINGCONSENT RELEASE FORM Tattoo Consent Form Client Consent Form Name * Please ensure your name is input correctly. First Name Last Name I acknowledge that tattoos are permanent in nature, using sterilized equipment, including single use needles and pigments. The pigments, inks and dyes used are not regulated by the Food and Drug Administration and the consequences of using these products are unknown. * Confirm I understand the tattooing process is damaging to the skin and can result in infection. If any complications should arrive, I should immediately seek medical attention. * Confirm I understand the aftercare process requires that I keep the new tattoo clean and well taken care of by washing the affected area and using recommended medications and/or ointments. * Confirm I have disclosed all current use of medications, prescriptions, and/or antibiotics to the Artist. * If you have any questions regarding a specific medication, prescription, or antibiotic, we advise you to speak with your healthcare professional. Confirm I fully understand the risks of exposure to bloodborne pathogens through both the tattooing and aftercare process. Additionally, I understand that sickness or illnesses may be a result of both the tattooing and aftercare process. * Confirm I have had a history of any of the following: Please check any boxes that apply. Allergic reactions to latex Diabetes Hemophilia or other bleeding disorders Cardiac valve disease Herpes at the proposed procedure site I, [Name], have been fully informed of the risks of tattooing, including, but not limited to; infection, scarring, difficulties in detecting melanoma, and allergic reactions to tattoo pigment, latex gloves and antibiotics. Having been informed of the potential risks associated with getting a tattoo, I still wish to proceed with tattoo application, and I assume any and all risks that may arise from tattooing. * I have been fully informed of the risks, and agree to proceed with tattoo application. Upload Government-Issued Identification (Drivers License, Passport, etc.) * FileField; MaxSize=10000KB; Multiple Electronic Signature: * Please provide an electronic signature by correctly typing your full name here. Procedure description: * I acknowledge that by signing this release form, that I have been given the full opportunity to ask any and all questions I might have about obtaining a tattoo at High Sierra Tattoo Co. I acknowledge that all my questions have been answered to my full and total satisfaction. I specifically acknowledge that I have been advised of the facts and matters set forth below, and I agree as follows: I am not under the influence of alcohol or drugs. * Confirm I do not have acne, freckles, moles, or sunburn in the area to be tattooed that may be agitated by the tattoo process (healing excluded). * Confirm I have looked over my design, checked the spelling (if applicable), and give my full consent to the application of my tattoo. * Confirm I acknowledge that I am not pregnant. * Confirm I acknowledge that I am free of communicable disease. * Confirm I acknowledge that I have truthfully represented to the artists, representatives and establishment of High Sierra Tattoo Co that I am over (18) years of age. * Confirm I acknowledge that it is not reasonably possible for the artists, representatives, and establishment of High Sierra Tattoo Co to determine whether I might have an allergic reaction to the dyes, pigments, or processes used in my tattoo and I agree to accept that such risks are possible. * Confirm I acknowledge that infection is always possible as a rseult of obtaining a tattoo, particularly in the event that I do not take proper care of my tattoo, and I have been advised of the signs and symptoms of infection that indicate a need to seek medical care. * Aftercare instructions are typically verbally delivered after the tattoo/piercing session. Additionally, you can find our written aftercare instructions here on our website. Confirm I acknowledge that variations in color and design may exist between any tattoos as selected by me and as ultimately applied to my body. * Confirm I acknowledge that tattooing is a permanent change to my appearance and that no representations have been made to me as the ability later to change, alter or remove my tattoo. * Confirm I acknowledge that the obtaining of my tattoo is my choice alone and I consent to the application of the tattoo and to any actions or conduct of the artists, representatives and establishment of High Sierra Tattoo Co that are reasonable to perform the tattoo procedure. * Confirm I agree to release and forever discharge and forever hold harmless High Sierra Tattoo Co and its artists, representatives and associates from any and all claims, damages, or legal actions arising from or connected in any way with my tattoo or the procedures and conduct used to apply my tattoo, and any and all tattoos applied at High Sierra Tattoo Co by its artists and representatives in the future. * Confirm I acknowledge that tattoo inks, dyes and pigments have not been approved by the federal Food and Drug Administration and the health consequences of using these products are unknown. * Confirm I acknowledged that there is a chance I might feel lightheaded or dizzy during or after being tattooed. I agree to immediately notify the practitioner in the event I feel lightheaded or dizzy, and/or if i may faint before, during, and/or after the procedure. * Confirm I agree to follow all instructions concerning the care of my tattoo, and that any touch-ups needed because my my own negligence will be done at my own expense. * Confirm Email * Please ensure your email is input correctly. Phone * Please ensure your phone number is input correctly. (###) ### #### Your form has been successfully submitted. We hope you enjoy your soon-to-be tattoo!For aftercare instructions, click here. Piercing Consent Form – Adult Piercing Client Consent Form Name * First Name Last Name I acknowledge by filling out and submitting this form that I have been given the full opportunity to ask any and all questions which I might have about obtaining a piercing from High Sierra Tattoo Co, and all my questions have been answered to my full and total satisfaction. I acknowledge I have been advised of the matters set forth below and I agree as follows: I am not pregnant or nursing. If i have any condition that might affect the healing of this piercing, I will inform my Piercer. * Confirm I do not suffer from medical or skin conditions such as, but not limited to: keloid or hypertrophic scarring, psoriasis at the site of the piercing or any open wounds or lesions at the site of the piercing. * Confirm - I have advised the Piercer of any allergies to metals, latex gloves, soaps and medications. I acknowledge it is not reasonably possible for the Piercer to determine whether I might have an allergic reaction to the piercing or processes involved in the piercing and further acknowledge that such a reaction is possible. * Confirm I have trustfully represented to the Piercer I am over the age of 18 years. I am not under the influence of drugs or alcohol. To my knowledge, I do not have any physical, mental or medical impairment or disability which might affect my well-being as a direct or indirect result of my decision to have a piercing done at this time. * Confirm I acknowledge that obtaining this piercing is my choice alone and will result in a permanent change to my appearance, and that no representation has been made to me as to the ability to later restore the skin involved in this piercing to its pre-piercing condition. * Confirm I acknowledge infection is always possible as a result of obtaining a piercing. I have received aftercare instructions and I agree to follow all of them while my piercing is healing. * Please note that aftercare instructions are typically provided after the piercing, but can be provided beforehand per request. Additionally, you can find our aftercare instructions here on our website. Confirm I understand I will be pierced using appropriate instruments and sterilization. * Confirm I understand that piercings usually take 3-6+ months to heal. * Confirm I agree to release and forever discharge and hold harmless the Piercer and all representatives of High Sierra Tattoo Co from any and all claims, damages or legal actions arising from or connected in any way with my piercing, or the procedure and conduct used in my piercing. * Confirm Electronic Signature * Please provide an electronic signature by correctly inputting your name into the field below. By submitting this form, you are agreeing to the validity of your electronic signature. Upload Government-Issued Identification (Drivers License, Passport, etc.) * FileField; MaxSize=10000KB; Multiple Email * Please ensure that your email is input correctly. Phone * Please ensure your phone number is input correctly. (###) ### #### Thank you! Piercing Consent Form – Parent/Legal Guardian for Minor Piercing Consent Form – Parent/Legal Guardian for Minor Name of Parent or Legal Guardian * First Name Last Name Name of Minor * First Name Last Name I acknowledge that I am the natural parent or legal guardian of: * The minor's Date of Birth is: * The child's age is: * I have the legal authority to give consent to the body piercing of this child. * Confirm I consent to the body piercing of my child as follows: * Electronic Signature * Please provide an electronic signature by correctly inputting your name into the field. By submitting this form, you are agreeing to the validity of this electronic signature. Upload Valid ID for Both Minor & Legal Guardian (State ID, Drivers License/School ID, Birth Certificate) * FileField; MaxSize=10000KB; Multiple Thank you!
