Consent and Release Form

OCTOPUS INK TATTOOS Jim Knoeppel
Consent to Tattoo and Release and Waiver of All Claims
I acknowledge by signing this release that I have been given full opportunity to ask any and all questions which I might have about obtaining a tattoo. And that all of my questions have been answered to my full and total satisfaction. I specifically acknowledge that I have been advised of the matters set forth below and agree as follows:
– I am not pregnant or nursing. I do not have epilepsy, diabetes or hemophilia. I do not suffer from any heart conditions or take medications that thin the blood. _____
– If I suffer from Hepatitis or any other communicable disease, I have informed the Tattoo Artist of this fact and have been advised of any medications or procedures necessary to promote satisfactory healing of my tattoo. _____
– I do not suffer from medical or skin conditions such as, but not limited to: Keloid or hypertrophy scarring, psoriasis at the site of the tattoo or any open wounds or lesions at the site of the tattoo. _____
– I have advised the Tattoo Artist of any allergies to metals, latex, soaps and medications. I acknowledge it is not possible for the Tattoo Artist to determine whether I might have an allergic reaction to the tattoo or process involved in the tattooing and further acknowledge that such a reaction is possible. List the allergies and conditions: ___________________________
– I have truthfully represented to the Tattoo Artist that I am over the age of 18 years. I am not under the influence of any drugs or alcohol. To my knowledge, I do not have any physical, mental, or medical impairment or disability, which might affect my judgment, and/or my well being as a direct, or indirect result of my decision to have a tattoo done at this time. _____
– I acknowledge that obtaining this tattoo is my choice 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 tattooing to the pre-tattooed condition. _____
– I acknowledge infection is always possible as a result of obtaining a tattoo, and I agree to follow all instructions concerning the care of my tattoo while it is healing. _____
– I understand I will be tattooed using appropriate instruments and sterilization techniques. _____
– Therefore, I authorize the tattoo artist to tattoo my _________________________. I understand this type of tattooing usually takes 2 weeks or longer to heal. I agree to release and forever discharge and hold harmless the Tattoo Artist and all employees from any and all claims, damages, or legal actions arising from or connected in any way with my tattooing, or the procedure and conduct used in my tattooing.
BY SIGNING THIS RELEASE, I SWEAR UNDER PENALTY OF PERJURY THAT I AM AT LEAST 18 YEARS OLD AND UNDERSTAND THAT I AM RECEIVING A TATTOO FROM A LICENSED TATTOO ARTIST IN ACCORDANCE WITH ALL STATE LAWS, RULES AND REGULATIONS.______
NAME____________________________ PHONE: _____________________DOB________________ ADDRESS:_________________________________________________________________________ __ DRIVERS LICENSE/I.D #__________________________STATE: _______________EXP:________ EMAIL:______________________________________________________________________ SIGNATURE:_____________________________________DATE:_________________

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