The Paper Lantern

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Let us do this part

Today's Date:

Wed Apr 16 2025 04:49

Practitioner:*

Tattoo placement:*

Tattoo design:*

Please read and answer

Medical History*

History of skin diseases, allergens or sensitivities. Any adverse reactions to latex, adhesives, ink pigments, dyes, metals.

Medical History*

Are you currently pregnant or breast feeding

Do you have Flu like symptoms?*

IF YOU HAVE:
- a fever
- flu-like symptoms
- shortness of breath

YOU NEED TO NOTIFY A STAFF MEMBER IMMEDIATELY.

Bloodbourne Pathogens*

Do you have any bloodbourne pathogens, transmittable diseases or recent illnesses? (It' okay if you do, we just want to know for our and other's safety).

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 do not have a mental impairment that may affect my judgment in getting the tattoo.

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, 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.

Waive*

TO WAIVE AND RELEASE to the fullest extent permitted by law each of the Artist and The Paper Lantern 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 any direct and/or consequential damages, which result or arise from my tattoo, whether caused by the negligence or fault of either the Artist or The Paper Lantern, or otherwise.

Healing*

The Paper Lantern has given me the instructions for aftercare of my tattoo. I understand them and will follow them. I acknowledge that it is possible that the tattoo can become infected. It can result in fever, swelling, redness, itchiness, fatigue, and possible dizziness/nausea. If any of these symptoms do not subside within a couple of days I will go immediately to an Urgent Care or contact my physician.

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.

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.

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 Paper Lantern

Photography*

I release all rights to any photographs/videos taken of me and the tattoo and give consent in advance to their reproduction in print or electronic form. (If you do not tick this provision, please advise your Artist).

Disclosure Statement /Notice for Filing Complaints

Public Act 375, which was enacted in December of 2010, indicates that individuals shall not tattoo, brand, or perform body piercing on another individual unless the tattooing, branding, or body piercing occurs at a body art facility licensed by the Michigan Department of Health and Human Services. Body art facilities are required to be in compliance with the “Requirements for Body Art Facilities,” which provide guidelines for safe and sanitary body art administration.

As with any invasive procedure, body art may involve possible health risks. These risks may include, but are not limited to: transmissions of bloodborne diseases such as HIV and viral hepatitis, skin disorders, skin infections, and allergic reactions.

In addition, persons with certain conditions including, but not limited to, diabetes, hemophilia or epilepsy, are at a higher risk for complications and should consult a physician before undergoing a body art procedure.

If you wish to file a complaint against a body art facility related to compliance with PA 375or have concerns about potential health risks, please visit www.michigan.gov/bodyart.

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.

Client Information

I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or legal guardian is in complete understanding and concurrence with this agreement.

Name:*

Address:

Postcode:

Date of birth:*

If you are under 18 your parent/guardian will be required

Phone #:*

Email:*

Signature:*

Sign above or type signature:

Emergency Contact

If something happens, your emergency contact might need to explain your medical history, allergies, or medications.

Name:

Phone #:

Photo ID*

Please take photo(s) of your government issued photo IDs and related paperwork.