Name *

First Name

Last Name

Phone *

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Birth Date *

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DD

YYYY

Appointment Date *

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DD

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Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone # *

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I acknowledge I am over the age of eighteen(18) or I acknowledge I am over the age of sixteen(16) and have a parent present and consenting to my tattoo procedure and that I have truthfully represented to Lover’s Peril Tattoo and it’s affiliates 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 Lover’s Peril Tattoo reasonably necessary to perform the tattoo procedure.

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I am not pregnant or nursing.

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I am not under the influence of alcohol or drugs.

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I have advised my tattoo artist of any conditions that may affect the healing and / or procedure of a tattoo which include but are not limited to diabetes, epilepsy, hemophilia, heart conditions or taking medication which thins the blood.

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I have advised my artist of any and all acne, scarring (keloid), eczema, psoriasis, rash, infection, lesion, freckles, moles or sunburn in the area to be tattooed that may interfere with said tattoo. I have advised my artist of any and all types of infection, rash, or lesion on my body.

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I understand it is possible for me to lose consciousness before, during or after the tattoo procedure. I understand that it is not reasonable for my artist to catch me should I lose consciousness. I forever hold harmless the affiliates of Lover’s Peril Tattoo for any such fall or loss of consciousness.

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I acknowledge it is not reasonably possible for the representatives and employees of Lover’s Peril Tattoo 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 and may develop spontaneously at any point in the future.

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I have received thorough aftercare instructions and have had the opportunity to ask any and all questions I may have about caring for my tattoo. I understand that it is my responsibility alone to care for and heal my tattoo. I understand that should I not properly care for my tattoo that it will not look as it was meant to. I agree that any touch-up work needed, will be done at my own expense.

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I understand that improper care and healing of a tattoo can result in but is not not limited to infection, contracting of communicable diseases, loss of skin, loss of muscle, loss of motor function, loss of limb and loss of life.

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I understand that variations in color and design may exist between any tattoo as selected by me and as ultimately applied to my body. I am aware that my skin tone, skin health, overall health, aftercare routine as well as other factors may affect the look of the healed tattoo compared to when the procedure was performed.

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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.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.

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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.

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I understand that my tattoo artist reserves the right to stop or decline the procedure at any point during the procedure and for any reason. I agree that should my tattoo artist stop the procedure due to but not limited to my behavior, belligerency, sobriety or pain tolerance that I shall incur any costs associated with additional procedure appointments needed to finish the procedure.

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I understand that Lover’s Peril Tattoo reserves all rights to use any photos of my tattoo for marketing and promotional purposes without any compensation to myself.

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I understand that if I elect to have my tattoo bandaged in a non sterile manner, I accept the risks therein which include but are not limited to infection, contracting of communicable diseases, loss of skin, loss of muscle, loss of motor function, loss of limb and loss of life.

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I hereby release and forever discharge and hold harmless all affiliates of Lover’s Peril Tattoo 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 performing my tattoo. Should I pursue legal action it shall be my responsibility to pay for any and all legal costs charged to Lover’s Peril Tattoo as a result.

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By electronically signing below, I agree that I have read and fully understood the tattoo waiver form provided by Lover’s Peril Tattoo and understand and agree to its terms in its entirety.

Electronic Signature

First Name

Last Name