Tidepool Tattoo — Release and Waiver of All Claims Name* Age* Phone* (Format: 000-000-0000) Address* Date of Birth (MM-DD-YYYY)* Date* Agreement 1. I understand that it is not reasonably possible for any Tattooer, Permanent Makeup Artist, or any other contractors working at Tidepool Tattoo to determine whether I might have an allergic reaction to tattoo pigments, equipment, or procedures. I accept all risks that such reactions are possible. 2. I acknowledge that infection is always possible as a result of obtaining a tattoo, especially in the event that I do not take proper care of my tattoo. I accept full responsibility for all risks of infection and complications. 3. I acknowledge that variations in color and design may exist between my tattoo and what I had envisioned or requested. I understand that the brightness and appearance of colors will vary depending on my skin type, tone, and other factors. 4. I acknowledge that receiving a tattoo or permanent makeup is a permanent change to my body and appearance. No representations have been made regarding the ability to later alter, remove, or reverse the tattoo. 5. I acknowledge that the process of tattooing may cause discomfort or pain, and I freely consent to receive this tattoo. 6. I release and hold harmless all Tattooers at Tidepool Tattoo from any and all liability related to tattooing, permanent makeup, aftercare, or outcomes. 7. I understand that the FDA has not approved tattoo inks or pigments for injection under the skin. 8. I affirm that I am not under the influence of alcohol or drugs. 9. I affirm that I am at least 18 years of age and that all information provided is true and correct. Signature* Save Clear Date* Health Questionnaire* Diabetes Heavy Bleeding (Hemophilia) Epilepsy Scarring/Keloiding T.B. Pregnant/Nursing Easy to Faint Anemic (thin blood) Heart Condition Eczema or Psoriasis Herpes at the procedure site Hepatitis (A,B,C) HIV/AIDS (carrier regardless of detection) Mitral Valve Prolapse None of these Other skin conditions that may affect tattooing: Other risk factors that may affect tattooing or healing: Have you eaten anything in the last 3 hours? By signing, I hereby acknowledge that I have answered honestly. Signature* Save Clear Date* Submit Form