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Today's Date:
Sat May 18 2024 10:18
Artist:
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Tattoo description and placement :
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Consent to application of tattoo and release/waiver of all claims
I acknowledge by signing this document that I have been given the opportunity to ask any and all questions which I might have about obtaining a tattoo, and that all of my questions have been answered to my full satisfaction. I specifically acknowledge that I have been advised of the facts and matters set forth below, and I agree as follows:
Please read and answer
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I agree to release and forever discharge and hold harmless Messe Noire Tattoo and its agents, employees, officers and shareholders from any and all claims or legal actions arising from or connected to in any way my tattoo or the procedure used to acquire such modifications.
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I acknowledge that I have truthfully represented to the agents of Messe Noire Tattoo that I am at least 18 years of age.
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I acknowledged that I am not under the influence of drugs or alcohol. All prescription drugs (including anticoagulants) that may affect my new tattoo must be discussed with the artist.
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I acknowledge that if I have any of the following health issues that I have thoroughly discussed it with my artist: (this information will be kept in strict confidence) Diabetes; Hemophilia; Skin disease or lesions; Pregnant or breast feeding; Neurological or immune compromised.
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I acknowledge that the obtaining of my tattoo is my choice alone, and I consent to the application of the tattoo, and to and to any actions of conduct by Messe Noire Tattoo's agents reasonably necessary to perform such a procedure.
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I acknowledge that, although I will be tattooed under the highest standard of sterilization possible, infection is always possible as a result of obtaining such a procedure; particularly in the event that I do not take proper care of my tattoo.
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I acknowledge that body modification is a permanent change to my appearance and no representations have been made to me as the ability to later change or remove such a procedure, other than laser removal, which may cause scarring.
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I acknowledge the receipt of verbal and written aftercare instruction and recommendations and I recognize the necessity for following the aforementioned instructions.
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I have notified the agents of Messe Noire Tattoo of any allergies to pigments, soaps, metals, etc.
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.
Client Information
I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement.
Legal Name:
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Pronoun:
-select-
He/Him
She/Her
They/Them
He/Them
She/Them
He/She
He/She/They
Chosen name:
Address:
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Postcode:
Date of birth:
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You must be 18 or older
Phone #:
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Email:
Signature:
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Sign above or type signature:
Parent/Legal Guardian
I, as custodial parent or legal guardian of the above minor under -18 years of age, hereby consent to the terms and conditions set forth in this release form and I attest that all documentation I have provided is true and accurate.
Guardian's Legal Name:
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Signature:
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Emergency Contact
If something happens, your emergency contact might need to explain your medical history, allergies, or medications.
Name:
Phone #:
Photo ID
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Please take photo(s) of your government issued photo IDs and related paperwork.
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