Wavier Form - ForeverInk Sanity

TATTOO & PIERCING WAIVER

Information

First Name

Last Name

Phone *

Street Address *

City

State/Province

ZIP / Postal Code

Emergency Contact Name *

Emergency Contact Phone *

Select Procedure Type

Choose one to continue. This selection determines the next set of questions.

Body Part to be Tattooed *

Design Description *

Upload file *

No file chosen

I accept full responsibility for the spelling and meanings of all text or symbols to be tattooed.Yes

Body Part to be Pierced *

Jewelry Style

Health Questions

Do you have any allergies (latex, iodine, etc)?YesNo

Explain

History of fainting? *YesNo

Explain

Hemophilia? *YesNo

Explain *

Heart condition?YesNo

Explain

Epilepsy/seizures? *YesNo

Explain

Diabetes? *YesNo

Explain

Currently taking blood thinners? *YesNo

Explain

Have you eaten within the last 4 hours? *YesNo

Explain

Under the influence of drugs/alcohol today? *YesNo

Explain

Pregnant or breastfeeding? *YesNo

Explain

Client Acknowledgment

I am at least 18 years of age or have legal guardian consent.I chose to receive this tattoo/piercing voluntarily.I understand the risks: infections, allergic reactions, scarring.I will follow all aftercare instructions.I confirm the equipment used was sterile and opened in front of me.I’ve had the opportunity to ask questions.

Signature & Consent

Signature *

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