WAIVER Name * First Name Last Name Phone * (###) ### #### Date of Birth * MM DD YYYY Artist Jose Portillo Ashton Glover (apprentice) Slow Portal Hana Guest artist * I agree that the procedure description of body art shown to me is correct to my specifications. I understand there is a possibility of scarring. I understand there is a possibility of difficulty in detecting melanoma. All questions about the body art procedure have been answered to my satisfaction, and I have been given the aftercare instructions for the procedure I am about to receive. I understand that tattooing is permanent and that if I chose to have it removed, it may be expensive and leave scars. I am the person on the legal ID presented as proof that I am at least 18years of age. I am not under the influence of alcohol, or any drugs and I am voluntarily submitting to be tattooed without duress or coercion. I understand there is a possibility of an allergic reaction and infection. I agree to follow all instructions concerning the care of my body art, and that any touch-ups due to my own negligence will be done at my own expense. I agree to immediately notify the artist in the event I feel lightheaded, dizzy and/or faint before, during or after procedure. I understand that tattoo inks, dyes, and pigment pigments have not been approved by the federal Food and Drug Administration (FDA) and that health consequences of using these products are unknown. Please check any conditions listed below that apply to you. Diabetes Epilepsy Faint/ Dizziness Heart Condition Tenderness Hemophilia Blood thinners Herpes Pregnancy/ nursing HBV T.B. Eczema/ Psoriasis Scarring/ Keloiding Skin Conditions Fever Asthma Allergic reaction to Latex Allergic reaction to antibiotics Bleeding disorder Other How long as it been since you last ate? * Have you been diagnosed with any blood-borne illnesses, such as HIV or Hepatitis B or C? * YES NO Are you currently taking any medications or drugs that may affect your ability to undergo a tattoo session? * YES NO Have you had any adverse reactions or allergic reactions to tattoo ink or other products used in the tattoo process in the past? * YES NO Have you traveled outside the country in the last 14 days? * YES NO Have you experienced any flu-like symptoms in the last 14 days including fever, cough, or shortness of breath? * YES NO Have you been in close contact with anyone who has been diagnosed with COVID-19 or has exhibited flu-like symptoms in the last 14 days? * YES NO Do you have a compromised immune system or underlying medical conditions that put you at higher risk of contracting COVID-19/ * YES NO Do you understand that COVID-19 is highly contagious and that there is a risk of exposure in public places such as a tattoo studio, despite our efforts to maintain a clean and safe environment? * YES NO I acknowledge that I have answered the above questions truthfully and to the best of my knowledge. I understand that the tattoo artist and the tattoo studio will take all necessary precautions to minimize the risks associated with getting a tattoo, but that there is still a risk of complications and that my tattoo artist and the tattoo studio will take all necessary precautions to minimize the risk of exposure to COVID-19, but that there is still a risk of exposure. I assume all responsibility for any complications that may occur and for any risk of exposure to COVID-19 that may occur as a result of my visit to the tattoo studio. I hereby release the tattoo artist, the tattoo studio, its owners, employees, agents, and affiliates from any and all liability for any injury, illness, or harm that may result from my visit to the tattoo studio. * First Name Last Name Date * MM DD YYYY Thank you!
