Consent Form Name(Required) First Last Address(Required) Street Address City State / Province / Region ZIP / Postal Code Today's Date(Required) Email(Required) Phone(Required)Date of Birth(Required) What is your race?(Required)HumanWhiteBlackHispanicOtherWhat is your sex?(Required)Male (XY)Female (XX)Prefer not to sayWhat is your physician's name, address and phone number?(Required) Which tattoo artist or body piercer?(Required)Heather FieldsBobby FieldsDerrick AllenJohn AlbrittonDesmond HunterTerri Castro-MooreBrett CothernTroy DiLannaBrandyn ZielbergAmanda KuesterEmergency Contact: (Name and Phone Number)(Required) Referred by: Brief Description of your Tattoo or Piercing(Required) Tattoo/Body Piercing Location on Body(Required) Please take a picture of the front of your driver's license and upload here:(Required)Max. file size: 5 MB.WELLNESS ACKNOWLEDGEMENT - I acknowledge and understand that Skinfinity Tattoo Company has put in place preventative measures to reduce the spread of any common cold, Flu or virus; however, infection from any of these can happen anywhere and no business can guarantee or completely prevent someone from becoming infected. Further, being in any business could increase your risk of contracting the common cold, Flu, or any virus. By signing this agreement, I acknowledge the contagious nature of germs and voluntarily assume the risk that I may be exposed to or infected by a cold, Flu, or virus by entering the shop and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by the common cold, Flu, or virus at the Facility may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Facility employees, contractors, representatives. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with being in the Facility and/or receiving services . On my behalf, I hereby release, covenant not to sue, discharge, and hold harmless the Facility, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Facility, its employees, agents, and representatives, whether an infection occurs before, during, or after receiving services within the facility. I confirm that I am not presenting any of the symptoms of a cold, Flu, or virus including dry cough, runny nose, sore throat, shortness of breath, loss of sense of taste or smell, fever.(Required) Yes No I understand that all sales transactions are final and deposits are non-refundable.(Required) Yes No Have you eaten today?(Required) Yes No RISKS/WAIVER - I acknowledge that I have been fully informed of the inherent risks, associated with getting a tattoo and/or body piercing. 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, latex gloves, and/or soap. Having been informed of the potential risks, I still wish to proceed with the tattoo or body piercing application and I freely accept and expressly assume any and all risks. I agree TO WAIVE AND RELEASE to the fullest extent permitted by law each of the Artist and the Studio 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 Tattoo Studio, or otherwise.(Required) Yes No HEALING - The Artist and the Tattoo Studio have given me instructions on the care of my tattoo and/or body piercing while it's healing, and I understand them and will follow them. I acknowledge that it is possible that the tattoo or body piercing 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.(Required) Yes No INFLUENCE - I am not under the influence of alcohol or drugs, and I am voluntarily submitting to be tattooed/pierced by the Artist without duress or coercion. Do you affirm this statement?(Required) Yes No Do you have any bloodbourne pathogens, transmittable diseases or recent illnesses? (It's okay if you do, we just want to know for our and other's safety).(Required) Yes No CURRENT PHYSICAL HEALTH (& BLOODBORNE PATHOGENS) - 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 tattoo or piercing. Do you affirm this statement?(Required) Yes No PREGNANT/NURSING: Are you pregnant or nursing?(Required) Yes No While a tattoo or piercing may only take a few minutes or hours to acquire, it is permanent. Tattoos can make you more susceptible to skin and blood infections. Specific risks include, but are not limited to: Bloodborne Diseases- your tattoo or piercing is contaminated with the blood of an infected person, you can contract a number of serious bloodborne diseases. These include Hepatitis B and C, tetanus, and HIV, the virus that causes AIDS. 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. I affirm these risks and understand the above statement.(Required) Yes No SPELLING/FADING/PERMANENCE - Neither the Artist nor the Tattoo 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. 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. I understand that 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. Do you affirm this statement?(Required) Yes No LEGAL ACTION - I agree to reimburse each of the Artists and the Tattoo Studio for any attorneys' fees and costs incurred in any legal action I bring against either the Artist or the Tattoo Studio and in which either the Artist or the Tattoo Studio is the prevailing party. I agree that the courts of Florida 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. Do you affirm this statement?(Required) Yes No QUESTIONS & UNDERSTANDING - 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 Tattoo Studio. Yes No LEGAL AGE - 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.(Required) Yes No PHOTOGRAPHY - I release all rights to any photographs taken of me and the tattoo or body piercing and give consent in advance to their reproduction in print or electronic form. (If you do not tick this provision, please advise your Artist). Yes No I AGREE AND ACKNOWLEDGE THAT I HAVE ANSWERED THESE QUESTIONS TRUTHFULLY AND TO THE BEST OF MY ABILITY. BY TYPING MY NAME BELOW, I AM USING THIS AS MY ELECTRONIC SIGNATURE AND SEALING THIS AGREEMENT. MY ELECTRONIC SIGNATURE:(Required) GUARDIAN'S LEGAL NAME (if consenting for a minor) GUARDIAN'S RELATIONSHIP TO MINOR: UntitledFirst ChoiceSecond ChoiceThird ChoiceUntitledFirst ChoiceSecond ChoiceThird ChoiceNameThis field is for validation purposes and should be left unchanged.