Heirloom Tattoo LLC Waiver

Let us do this part

Today's Date:

Tue Nov 12 2024 08:20

Practitioner:*

Location of tattoo on body:*

Tattoo Description:*

Tattoo Price (rough estimates are okay, skip this question if you don't know):

Please fill out this form prior to getting tattooed, and have your valid photo ID ready to show your artist at your appointment.

Please also fill out the *entire* form, even the "let your artist do this part" section!

License # BA-02646

Please read and answer

Eaten*

Have you eaten in the past 4hrs?

Do you have any Flu like symptoms?*

IF YOU HAVE:
- a fever
- flu-like symptoms
- shortness of breath
- congestion/runny nose
- a temperature

Notify a staff member immediately if yes.

Bloodborne Pathogens*

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

Waive*

I agree to waive and release to the fullest extent permitted by law both the Artist and/or Heirloom Tattoo LLC 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 and/or Heirloom Tattoo LLC or otherwise.

Healing*

The Artist and/or Heirloom Tattoo LLC 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.

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.

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.

Spelling*

I have approved the spelling, meaning, and color choices of my design. Neither the Artist nor the 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.

Fading*

Variations in color/design may exist between the art I have approved 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.

Health*

Please check yes if you have any of the following conditions, note below any details, and verbally inform your artist. Check no if none of these statements apply.

Diabetes, epilepsy, hemophilia, a heart condition, currently taking blood thinning medication, or 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 prescribed to me. I am not pregnant or nursing. I do not have a mental impairment that may affect my judgment in getting the tattoo.

Details:

Risks*

I fully understand that risks related to getting a tattoo, both 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 associated with getting a tattoo, 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.

Legal Action*

I agree to reimburse each of the Artist and the Studio for any attorneys' fees and costs incurred in any legal action I bring against either the Artist or Heirloom Tattoo LLC and in which either the Artist or the Studio is the prevailing party. I agree that the that the courts of Michigan in the U.S.A. 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.

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, and I understand that I am signing a legal contract waiving certain rights to recover against the Artist and Heirloom Tattoo LLC.

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. (If you do not tick this provision, please advise your artist).

How did you hear about us?

Aftercare Sheet*

Client has received a copy of the Aftercare Information Sheet if requested (this will be given in-studio, or found on our website at heirloomartsllc.com/aftercare)

Disclosure Statement*

Client has acknowledged the Disclosure Statement and Notice for Filing Complaints (posted in studio)

Completed Waiver*

Client has completed the Client Health Questionnaire, and received any additional, applicable information (you have completed this waiver in full)

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.

Legal Name:*

Pronoun:

Chosen name:

Address:*

Postcode:*

Date of birth:*

You must be 18 or older

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.