WAIVER, RELEASE, AND CONSENT TO TATTOO

WAIVER, RELEASE, AND CONSENT TO TATTOO

AND MEDICAL HISTORY FORM

In consideration of receiving a tattoo from Near Me Tattoo (together with its employees, apprentices and agents, the Near Me Tattoo), I agree to the following:

That I, ____________________________________ (clearly PRINT your name) have been fully informed of the inherent 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 detecting melanoma and allergic reactions to tattoo pigment, latex gloves, and/or soap. Having been informed of the potential risks associated with getting a tattoo, I still wish to proceed with the tattoo application and I freely accept and expressly assume any and all risks that may arise from tattooing.

______TO WAIVE AND RELEASE to the fullest extent permitted by law each of the Artist and the Tattoo Studio from all liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise, including any direct and.or consequential damages, which result or arise from the application of my tattoo, whether caused by the negligence or fault of either the Artist or the Tattoo Studio, or otherwise.

______I understand that a tattoo is a permanent artwork on skin created by injecting ink pigments into the second layer of skin (dermis), using a specialized, sterilized needle. The procedure involves a tattoo machine that rapidly moves the needle to deposit ink beneath the surface of the skin. The skin will be cleaned and, if necessary, shaved. A stencil or freehand design will be applied as a guide. During the procedure, mild to moderate discomfort, redness, and swelling may be experienced. After the tattoo is complete, the area will be cleaned and covered with a dermshield, as known as transparent bandage, to protect it during the healing process. Following proper aftercares from the aftercare instruction, which will be handed before and after the procedure, is the client's responsibility and is required to ensure healing and prevent infection.

______I understand that a tattoo is a permanent change to my appearance and can only be removed by laser or surgical means, which can be disfiguring and/or costly and which in all likelihood will not result in the restoration of my skin to its exact appearance before being tattooed.

______Neither the Artist nor the Tattoo Studio is responsible for the meaning or spelling of the symbol or text that I have provided to them or chosen from the flash (design) sheets.

______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 will fade due to unprotected exposure to the sun and the naturally occurring dispersion of pigment under the skin. 

______That both the Artist and the Tattoo Studio have given me the full opportunity to ask any and all questions about the application of my tattoo and all of my questions have been answered to my total satisfaction.

______I am not under the influence of alcohol or drugs, and I am voluntarily submitting to be tattooed by the Artist without duress or coercion.

______I do  not have diabetes, epilepsy, hemophilia, a heart condition, nor do I take blood thinning medication. I do not have any other medical or skin condition that may interfere with the application or healing of the tattoo. I am not the recipient of an organ or bone marrow transplant or, if I am, I have taken the prescribed preventive regimen of antibiotics that is required by my doctor in advance of any invasive procedure such as tattooing or piercing. I am not pregnant or nursing. I do not have a mental impairment that may affect my judgment in getting the tattoo.

______I understand the restrictions on physical activities, gardening, contact with animals, and the durations of the restrictions.

______I release all rights to any photographs and videos taken of me and the tattoo and give consent in advance to their reproduction in print or electronic form. (If you do not initial this provision, please advise and remind your Artist and the Tattoo Studio NOT to take any pictures or videos of you and your completed tattoo!).

______ I agree to reimburse each of the Artist and the Tattoo Studio for any attorneys’ fees and costs incurred in any legal action I bring against either the Artist or the Tattoo Studio and in which either the Artist or the Tattoo Studio is the prevailing party. I agree that the courts of California in Alameda County shall have personal jurisdiction and venue over me and shall have exclusive jurisdiction for the purpose of litigating any dispute arising out of or related to this agreement.

______ I acknowledge that I have been given adequate opportunity to read and understand this document, that it was not presented to me at the last minute, and I understand that I am signing a legal contract waiving certain rights to recover against the Artist and the Tattoo Studio.

Notice:   * HIPAA Requirements: Any medical information obtained will be subject to the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

* Tattoo inks: Tattoo inks, dyes, and pigments have not been approved by the Federal Food and Drug Administration and that the health consequences of using these products are unknown.

MEDICAL HISTORY

Please circle any conditions listed below that apply to you.

TB

Asthma

Antibiotic Allergies

Hemophilia

HIV

Hepatitis

Cardiac Valve Disease

Scarring/Keloiding

Epilepsy

Skin Conditions

Pregnant/Nursing

MRSA/Staph Infections

Diabetes

Blood Thinners

Fainting/Dizziness

Latex Allergies

When was the last time you ate? _________________________________________________________________

How many hours did you sleep last night? _________________________________________________________

Do you have any additional allergies to metals, soaps, cosmetics or alcohol? ______________________________

Do you have a history of medical use or is currently using medication, including being prescribed Antibiotics prior 

to this tattoo procedure? ________________________________________________________________________

Do you use any medications that might affect the healing of the body art?_________________________________

Do you have a history of herpes or any other skin conditions? __________________________________________

Other medical conditions? ______________________________________________________________________

If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be served from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.

I hereby declare that I am of legal age (and have provided valid proof of age) and am competent to sign this Agreement. 

I HAVE READ THIS AGREEMENT, I UNDERSTAND IT, I AGREE TO BE BOUND BY IT.