ETERNA TATTOO STUDIO

Parental/Guardian Waiver

First Name

Last Name

Phone Number

Email Address

Date of Birth

Parent/Guardian Name

Parent/Guardian Phone Number

Name of Tattoo Artist

Medical Information

Are you pregnant and/or breast-feeding?

Yes

Are you a hemophiliac or on any medications that may cause bleeding and/or hinder blood clotting?

Yes

Are you under the influence of alcohol and/or drugs, prescribed or otherwise?

Yes

Do you have a heart condition/epilepsy/diabetes?

Yes

Do you have any communicable diseases? (eg HIV, AIDS, Hepatitis)

Yes

Do you have any allergies? (medication or topical solutions)

Yes

If you answered yes to any question, please elaborate:

Consent Agreement

To my knowledge, I do not have any medical or mental impairment or disability which might affect my well being as a direct or indirect result of my decision to have any tattoo procedure done at this time.

I acknowledge and agree

I agree to follow all instructions concerning the care of my tattoo while it is healing. I agree that any touch up work, due to my negligence, will be at my expense.

I acknowledge and agree

I understand that if my skin is dark, the colours will not appear as bright as they do on lighter skin. Additionally, I understand that the finished tattoo may vary somewhat in appearance, colour, and/or design from the paper or other drawing or photograpic image which the tattoo design is based on.

I acknowledge and agree

Being of sound mind and body, I hereby release any and all employees, agents, or persons representing ETERNA TATTOO STUDIO from all responsibility. I agree not to sue ETERNA TATTOO STUDIO or its heirs or assigns in connection with any and all damages, claims, demands, rights, and causes of action of whatever kind or nature based upon injuries or property damages to or death of myself or any other persons arising from my decisions to have any tattoo related work at this time, whether or not caused by any negligence of ETERNA TATTOO STUDIO employees.

I acknowledge and agree

I agree for myself, my heirs, assigns, and legal representatives to hold harmless from all damages, actions, causes of action, claim judgments, costs of litigations, attorney's fees, and all other costs and expenses which might arise from my decision to have any tattoo work done by ETERNA TATTOO STUDIO.

I acknowledge and agree

I am aware that the tattoo will be permanent and that it can only be removed with a surgical procedure, and that any effective removal may leave permanent scarring and disfigurement.

I acknowledge and agree

I agree to pay for any and all damages and injuries to any persons and property belonging to ETERNA TATTOO STUDIO or any other person to whom they may be liable contractually or by operation of law, caused by or resulting from my decision to have tattoo work by ETERNA TATTOO STUDIO.

I acknowledge and agree

I hereby grant irrevocable consent to and authourize the use of any reproduction by ETERNA TATTOO STUDIO, any and all photographs which are taken this day of me, negative or positive proof which will be hereby attached for any purposes whatsoever, without further compensation to me. All negatives, together with the prints, video, or live internet stream shall become and remain property of ETERNA TATTOO STUDIO, solely and completely.

I acknowledge and agree

I agree the above information is true and correct. I have been made aware that if I have any signs or symptoms of infection, such as excessive swelling, pain, redness, warmth, fever, unusual discharge or odour to contact my physician. It is also my responsibility to take care of my new tattoo according to the instruction provided both verbally and in writing.

I acknowledge and agree

I declare the information I have provided is accurate and correct.

I request the Tattoo Artist to tattoo my son/daughter/legal dependent. I agree to release and forever discharge and hold harmless the Tattooer and all employees from any and all claims, damages, or legal actions arising from or connected in any way with the tattoo, or procedure/conduct used in his/her/their tattoo.

I acknowledge and agree

By my signature below, I certify that I am the parent/legal guardian of stated tattooee who is submitting willingly to these procedures.

I acknowledge and agree

Parent/Guardian Signature

Tattooee Signature

Parent/Guardian Printed Name

Tattooee Printed Name

Today's Date

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ETERNA TATTOO STUDIO

eternatattoostudio@gmail.com