Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

* 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. *

Yes

No

* 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 tattooist. I am not pregnant or nursing. I am not under the influence of alcohol or drugs. *

Yes

No

* I do not have medical or skin conditions such as but not limited to: acne, scarring (Keloid), Eczema, psoriasis, rash, infection, lesion, freckles, moles or sunburn in the area to be tattooed that may interfere with said tattoo. If I have any type of infection, rash, or lesion anywhere on my body, I will advise my tattooist. *

Yes

No

* I acknowledge it is not reasonably possible for the representatives and employees of this tattoo shop 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. *

Yes

No

* 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 or failure to follow such instructions, will be done at my own expense. *

Yes

No

* 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. *

Yes

No

* 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 have a tattoo. *

Yes

No

* I acknowledge I am over the age of eighteen and that I have truthfully represented to my tattooist 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. *

Yes

No

* I understand that Kit Corbett reserves all rights to use any photos of my tattoo taken in Gentle Biscuits. *

Yes

No

* I hereby release and forever discharge and hold harmless Kit Corbett, the Tattooist and all affiliates, Owners, Managers and Employees from any and all claims, damages or legal actions arising from or connected in any way with my tattoo, or the procedure and conduct used in my performing my tattoo, to the fullest extent allowed by the law. *

Yes

No

Today's Date *

MM

DD

YYYY