health form

Search by typing & pressing enter

YOUR CART

Waiver, Release and Consent to Tattoo Form

* Indicates required field

Name *

First

Last

Email *

Date (MM/DD/YYYY) *

Phone Number *

Select Artist (the artist that I have selected will be referred to as 'my artist' in this consent form.) *

I am over the age of 18, not pregnant or nursing, and I am not under the influence of any drugs or alcohol *

Yes

I truthfully presented my artist with the valid ID to prove that I am 18 years of age of older *

Yes

I do not have any medical or skin conditions that may interfere with the application or healing of the tattoo, or any communicable disease *

Yes

I do not have any medical impairment that may affect my judgement in getting the tattoo *

Yes

I have looked over my design, checked the spelling if applicable, and give my full consent to the application of my tattoo *

Yes

I understand that it is not reasonably possible to determine whether or not I may have a reaction to the dyes, pigments, or process used during the tattoo. I accept and agree that such risks are possible. *

Yes

I understand that variations in colour, and design may exist between tattoo art and the actual tattoo when it is applied to my body. I also understand that the colour and clarity of my tattoo will change over time. *

Yes

I acknowledge that infection is always possible as a result of obtaining a tattoo especially 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. *

Yes

I understand that a tattoo is a permanent change to my appearence *

Yes

I agree that any touch up work needed due to my own negligence will be done at my own expense *

Yes

I consent to the tattoo and procedure, and agree to accept all risk and responsibilities *

Yes

I agree to release, forever discharge and forever hold harmless my artist from any and all liability, claims and damages or legal actions arising from or connected in any way with my tattoo or the procedures and conduct used to apply my tattoo. *

Yes

I have read and understand this form and waive and release the artist and all persons involved with Lighthouse Studio *

Yes

Please fill out Needle Lot # in the space below ( since all needles used for the tattoo are new and come in a sealed package to prevent any potential cross-contamination). (Please ask your artist for this number/numbers) *

Submit