Williamsburg Brooklyn Tattoo Shop
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FUNDRAISER
CONSENT FORM
WAIVER, CONSENT, & RELEASE FOR TATTOO PROCEDURE
Please read and be certain you understand the implications of signing.
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Indicates required field
Full Legal Name
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First
Last
Preferred name (if different from legal name).
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Phone Number
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Name of your tattoo artist.
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In the next section, read and INITIAL IN EACH BOX to indicate
you understand and agree to the above provision.
I acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions which I might have about the obtaining of a tattoo and that all of my questions have been answered to my full satisfaction. I 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 fully informed of these risks 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.
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Insert FULL NAME here
TO WAIT AND RELEASE to the fullest extent permitted by law both 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, and/or assignees 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.
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If I have any condition that might affect the healing of this tattoo, I will advise my tattooer. If I have diabetes, epilepsy, hepatitis, hemophilia, HIV-AIDS, or any other communicable disease, heart condition or take medicine which thins the blood, I will advise the Artist. I am not the recipient of an organ or bone marrow transplant, or, if I am, I have taken the prescribed preventative regiment of antibiotics that is required by my doctor in advance of any invasive procedure such as tattooing.
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I am not pregnant or nursing. 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.
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I do not have medical or skin conditions such as but not limited to: acne, scarring (Keloid) eczema, psoriasis, freckles, moles or sunburn in the area to be tattooed that may interfere with said tattoo. If I have any type of infection or rash anywhere on my body, I will advise my tattooer.
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I acknowledge it is not reasonably possible for the representatives and employees of this tattoo shop to determine whether I might have an allergic reaction to the pigments or processes used in my tattoo, and I agree to accept the risk that such a reaction is possible.
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I acknowledge that infection is always possible as a result of the obtaining of a tattoo, particularly in the event that I do not take proper care of my tattoo. I have received aftercare instructions and I agree to follow them while my tattoo is healing. I agree that any touch-up work needed, due to my own negligence, will be done at my own expense.
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I realize that variations in color and design may exist between any tattoo as selected by me and as ultimately applied to my body. I understand that if my skin color is dark, the colors will not appear as bright as they do on light skin. I also understand that over time, the colors and clarity of my tattoo will fade due to unprotected exposure to the sun and naturally occurring dispersion of pigment under the skin.
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I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my tattoo.
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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.
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I acknowledge that a tattoo is a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove my tattoo. To my knowledge, I do not have a 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 tattoo.
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I release all rights to any photographs taken of me and the tattoo and give consent in advance to their reproduction in print and/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 of you and your completed tattoo.)
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I agree to reimburse both the Artist and the Tattoo Studio for any attorney related 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 New York in Kings 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.
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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.
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I acknowledge I am over the age of eighteen and that I have truthfully represented to my tattooer, provided valid proof of age and that the obtaining of a tattoo is by my choice alone. I consent to the application of the tattoo and to any actions or conduct of the representatives and employees of the tattoo shop reasonably necessary to perform the tattoo procedure.
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If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall
be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had
never been contained in this document.
New York City law clearly states that tattoo artists may NOT tattoo any individual under the age of 18. NO EXCEPTIONS;
parental consent not withstanding.
Do you have any known allergies? If yes, please list.
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Date of Birth (MM/DD/YY)
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Valid ID, Drivers License, or Passport #
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License or Passport photo
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Max file size: 20MB
Upload a clear photo of your valid state driver's license or passport.
*Note that you will still need to bring valid photo ID to your appointment
(drivers license or passport).
Address
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Line 1
Line 2
City
State
Zip Code
Country
COVID 19 screening
Do you or someone with whom you have had close contact have COVID19 or related symptoms such as fever, cough, shortness of breath, aches, loss of taste or smell, purple marks on the bottom of your feet or pink eye?
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Yes
No
Have you been to any gatherings, indoors or outdoors, in the past 2 weeks (i.e. family gatherings, protests, bars)?
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Yes (without precautions like a mask)
Yes (with precautions including wearing a mask)
No
Have you been recently screened or tested for COVID 19 ?
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Yes
No
If you have been screened/tested, what were your results?
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Positive
Negative
Date of COVID19 screening
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Please read and agree the following temporary shop rules by checking them off.
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I understand that I am to wear a mask at all times while inside the shop. No mask, no entry.
I will sanitize or wash my hands upon entry. I understand that gloves will be provided upon request.
I will respect social distancing guidelines and remain 6 feet away from everyone in the shop except by my tattooer during the tattoo.
I will come alone to my appointment to help reduce the number of guests in the shop at a time.
I HAVE READ THE FULL AGREEMENT ABOVE, I UNDERSTAND IT, I AGREE TO BE BOUND BY IT BY E-SIGNING IN THE BELOW BOX.
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By typing your name here you are agreeing that this is a legally binding signature.
Today's date (MM/DD/YYYY)
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Submit
HOME
about
portfolios
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FUNDRAISER
CONSENT FORM