Today's Date *

MM

DD

YYYY

Name *

First Name

Last Name

Preferred name

Something else you'd like us to call you?

First Name

Last Name

Phone *

(###)

###

####

I have eaten in the past 4 hours *

YES

Do you have any bloodbourne pathogens, transmittable diseases, or recent illnesses? (It's okay if you do, but for safety purposes, alert your artist) *

YES

NO

Age of Consent *

I am over the age of 18, or I am here with my legal parent/guardian whose legal information is also on this form.

YES

I WAIVE AND RELEASE *

to the fullest extent permissed by law each of the artists and the Kindred Spirit Tattoo Co. from all liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors, or assigns may have for personal injury or otherwise, including and direct and/or consequential damages, which result or arise from my tattoo; whether causes by the negligence or fault of the artist, studio, or otherwise.

YES

Healing *

The Artist and the The Kindred Spirit Tattoo Co. have given me instructions on the care of my tattoo while it's healing, and I understand them and will follow them. I acknowledge that it is possible that the tattoo can become infected, particularly if I do not follow the instructions given to me. If any touch-up work to the tattoo is needed due to my own negligence, I agree that the work will be done at my own expense.

YES

Risks *

That 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 informed of the potential risks, I still wish to proceed with the tattoo application and I freely accept and expressly assume any and all risks.

YES

Influence *

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.

YES

Health *

I do not have diabetes, epilepsy, hemophilia, a heart condition, nor do I take blood thinning medication. I do not have any other condition that may interfere with the application or healing of the tattoo. I am not the recipient of an organ or bone marrow transplant or, if I am, I have taken the preventive anti-biotics. I am not pregnant or nursing. I do not have a mental impairment that may affect my judgment in getting the tattoo.

YES

Spelling *

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 or chosen from the flash (design) sheets.

YES

Fading *

Variations in colour/design may exist between the art I have selected and the actual tattoo. I also understand that over time, the colors and the clarity of my tattoo will fade due to natural dispersion of pigment under the skin.

YES

Permanent *

A tattoo is a permanent change to my appearance and can only be removed by laser or surgical means, which can be disfiguring and/or costly and which in all likelihood will not result in the restoration of my skin.

YES

Legal Action *

I agree to reimburse each of the Artist and the Tattoo Studio for any attorneys' fees and 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 that the courts of Pennsylvania 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.

YES

Questions *

I acknowledge that I have been given adequate opportunity to read and understand this document, that any and all of my questions have been answered, 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 Kindred Spirit Tattoo Co.

YES

Photography *

I release all rights to any photographs taken of me and the tattoo and give consent in advance to their reproduction in print or electronic form.

YES