Tattoo Release Form Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone (###) ### #### Date of Birth * Tattoo Description * Body Location * Appointment Date * MM DD YYYY Health Questionaire- Please select all that apply * Do you have any allergies? Antibiotics Metals Soaps Latex Derm Sheild/Saniderm Alcohol Cosmetics Adhesives (bandaids) Petroleum Lanolin Oil Lidocaine Shellfish None Diseases * Hepatitis Tuberculosis HIV/AIDS Herpes Staph Auto Immune Asthma Covid 19 NONE Overall Health * Heart Disease High Blood Pressure Diabetes Pregnant or Breastfeeding Prone to Fainting Skin Disease/Rash Psoriasis Prone to Scarring/ Keloids Blood Thinners Eczema NONE Emergency Contact Info * Name and Phone Number Are you currently on an Medications Acknowledgment and Waiver * By completing and signing this form, I acknowledge that I have been given the full opportunity to ask any and all questions which I might have about obtaining a tattoo from THORN TATTOO ARTISTS, 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 facts and matters set forth, and I agree as follows: I have truthfully represented to THORN TATTOO that I am over the age of eighteen (18). I acknowledge that it is not reasonably possible for THORN TATTOO OR ITS ARTISTS to determine whether I might have an allergic reaction to the dyes, pigments or processes used in my tattoo, and I agree to accept the risk that such a reaction is possible. I acknowledge that I have advised my tattoo artist of any condition that might affect the healing of this tattoo. 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. I am not pregnant or nursing. I am not under the influence of alcohol or drugs. I acknowledge that infection is always possible as a result of obtaining 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. This includes sun and ultraviolet frequency damage. I acknowledge that if my tattoo is a symbol, or something written in a language other than English, that Thorn Tattoo or its artists are not responsible for what it may or may not mean. I acknowledge that if my tattoo includes text, that I am responsible for the correct spelling, grammar and punctuation. I have proofed the text before it is applied as a tattoo. I agree that the tattoo design is correctly drawn to my specifications and I agree to allow for artist interpretation of the image. I Agree Thank you!
