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Fresh Ink Tattoo IOM Consent/Disclaimer Form

Who is your artist

Location of tattoo on your body

Description of your tattoo

Pre-Procedure Questionnaire

Do you suffer from any heart conditions (e.g. prosthetic heart valve/ heart valve disease/ angina or blood pressure problems?
Do you suffer from epilepsy? If you answered YES for epilepsy, how is it controlled?
Do you suffer from hemophilia/other clotting disorders?
Do you suffer from diabetes or lupus?
Do you suffer from any skin problems when it comes to healing in the past such as eczema, psoriasis?
Do you suffer from "lumpy" raised scars (keloid scars)
Do you suffer from any allergies or known allergic responses e.g.(plasters, creams, metals, iodine, shellfish, latex,food stuff, other? If you have answered YES following the question above, please indicate which?
Do you take any prescribed medications regularly, (especially any anticoagulants such as Warfarin or high dose of aspirin; any immunosuppressants such as steroids)?
Are you, or think you could be pregnant?
Are you prone to fainting attacks?
Do you smoke?
Any known/previous reactions to dye pigments?

Acknowledgment and Waiver

I acknowledge by signing this agreement that I have been given the full 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 agree photos of my tattoo will be used in marketing unless otherwise requested. I specifically acknowledge I have been advised of the facts and matters set forth below and I agree as follows:

If I have any condition that might affect the healing of this tattoo, I will advise my tattooer, I am not pregnant or nursing. I am not under the influence of drugs or alcohol.
I do not have medical or skin conditions such as but not limited to: acne, scarring (Keloid) eczema, psoriasis,freckles, moles or sunburn in the area to be tattooed that may interfere with said tattoo. If I have any type of infection or rash anywhere on my body, I will advise my tattooer.
I acknowledge it is not reasonably possible for the representatives and employees of this tattoo shop (Fresh Ink IOM) to determine whether I might have an allergic reaction to the pigments or processes used in my tattoo, and I agree and to accept the risk that such a reaction is possible.
I acknowledge that infection is always possible as a result of the obtaining of a tattoo, particularly in the event that I do not take the proper care of my tattoo. I have received aftercare instructions and I agree to follow them while my tattoo is healing. I agree that any touch-up work needed, due to my own negligence,will be done at my own expense.
I realize that variations in colour and design may exist between any tattoo as selected by me and ultimately applied to my body. I understand that if my skin colour is dark, the colour will not appear as bright as they do on light skin.
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. 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.
Acknowledge I am over the age of 18 and that I have fully truthfully represented to my Tattooist 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 employees of the tattoo shop (Fresh Ink Tattoo IOM) reasonably necessary to perform the tattoo procedure.
I acknowledge I have fully read the fine print by initialing here. Otherwise I knowledge I am a douchebag.

Thanks for submitting!

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