Tidepool Tattoo — Release and Waiver of All Claims Name* Age* Driver’s License Number* Phone* (Format: 000-000-0000) Address* Date of Birth (MM-DD-YYYY)* Date* Agreement I acknowledge that the procedure being performed is body art, including but not limited to tattoos, permanent makeup, or esthetician services such as brows, lashes, or other care services provided by contractors working at Tidepool Tattoo. 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 or applying permanent makeup, which is done by breaking open the epidermis layer of skin using needles or other tools designed to access the dermis layer in order to deposit pigments and alter the appearance of skin, may cause discomfort or pain, and I freely consent to receive this tattoo. 6. I release and hold harmless all Tattooers, Permanent Makeup Artists, Estheticians, and any other contractors working at Tidepool Tattoo, as well as Tidepool Tattoo and its owner(s), from any and all liability related to tattooing, permanent makeup, other personal care services, aftercare, or outcomes. 7. I understand that the Federal Food & Drug Administration has not approved tattoo inks or pigments for injection under the skin and that the health consequences of the application of these pigment is unknown. 8. I understand and acknowledge that all Tattooers, Permanent Makeup Artists, Estheticians, and any other individuals performing services at Tidepool Tattoo are independent contractors and are not employees, agents, partners, or representatives of Tidepool Tattoo or its owner(s). 9. I agree to indemnify, defend, and hold harmless Tidepool Tattoo, its owner(s), and all independent contractors from any and all claims, liabilities, damages, losses, or expenses (including reasonable attorney’s fees) arising out of or related to the services performed. 10. I affirm that I am not under the influence of alcohol or drugs. 11. 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* History of allergic reactions to latex or antibiotics History of or current medication use (including antibiotics for procedures) If yes, list medications and duration (optional): 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 (any type) HIV/AIDS (regardless of detection status) Mitral Valve Prolapse None of these Any other allergies that may affect the procedure: 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
