Name *

First Name

Last Name

Address *

Address 1

Address 2

City

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Date of Birth *

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I would like to be added to the Thorns email newsletter list

I acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions which I might have about the obtaining of a tattoo and that all of my questions have been answered to my full satisfaction. I specifically acknowledge I have been advised of the facts and matters set forth below and I agree as follows: *

I understand that a tattoo is permanent art created on my skin through the use of specialized tattoo equipment, including sterile, single use tattoo needles, and tattoo ink. The tattoo procedure involves utilizing tattoo needles, and in most cases a tattoo machine, to penetrate the skin to deposit tattoo ink into the dermis layer of the skin.

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I am not under the influence of drugs or alcohol.

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I am not pregnant or breast feeding.

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If I have any condition that might affect the healing of this tattoo, I will inform my tattooer.

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If I have diabetes, epilepsy, hepatitis, hemophilia, HIV-AIDS or any other communicable disease, heart condition or take medicine which thins the blood I have advised my tattooer.

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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.

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I acknowledge it is not reasonably possible for my tattoo artist to determine whether I might have an allergic reaction to the pigments or processes used in my tattoo, and I agree to accept the risk that such a reaction is possible.

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I acknowledge that infection is always possible as a result of the obtaining of 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.

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I realize that variations in color and design may exist between any tattoo as selected by me and as ultimately applied to my body. I understand that colors might heal and appear differently on my skin than the bottle.

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I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my tattoo.

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I understand that tattoo inks, dyes, and pigments have not been approved by the federal Food and Drug Administration and the health consequences of using these products is unknown.

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I acknowledge that a tattoo is a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove my tattoo. To my knowledge, I do not have a physical, mental or medical impairment or disability which might affect my well being as a direct or indirect result of my decision to receive a tattoo.

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I acknowledge I am over the age of eighteen and that I have truthfully represented to my tattooer that the obtaining of a tattoo is by my choice alone. I consent to the application of the tattoo and to any actions or conduct of the representatives and employees of the tattoo shop reasonably necessary to perform the tattoo procedure.

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I fully understand THE TATTOO ARTIST DOES NOT ACT AS A MEDICAL PROFESSIONAL. Any suggestions made to me are NOT to be construed as or substituted for advice from a medical professional.

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I consent to the application of the tattoo and to any actions or conduct of the representatives and employees of the tattoo shop reasonably necessary to perform the tattoo procedure.

Medical Questionnaire

Please check any of the below items that apply to you:

I am pregnant.

I have a history of Herpes infection at the proposed procedure site.

I have a history of Diabetes.

I have a history of allergic reactions to latex.

I have a history of allergic reactions to antibiotics.

I have a history of Hemophilia or another bleeding disorder.

I have a history of Cardiac Valve Disease.

I have a pacemaker.

I am currently taking antibiotics, including for a dental or surgical procedure.

I have a history of antibiotics use.

I am currently taking prescription medications.

COVID-19 Liability Release Waiver *

Due to the 2019-2020 outbreak of the novel Coronavirus (COVID-19), our business is taking extra precautions with the care of every client to include health history review and enhanced sanitation/disinfecting procedures in compliance with CDC guidance. Symptoms of COVID-19 include: • Fever • Fatigue • Dry Cough • DifficultyBreathing I agree to the following:

I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days.

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I affirm that I, as well as all household members, have not been diagnosed with COVID-19 within the past 30 days.

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I understand that Thorns Tattoo cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each client.

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