Artist *

Full Name *

Address

Date of birth

Age

Email *

Phone *

Do you have allergies?

Yes

Do you have Flu like symptoms? *

Yes

If you have a fever, flu-like symptoms, or shortness of breath, YOU NEED TO NOTIFY A STAFF MEMBER IMMEDIATELY.

Bloodbourne Pathogens

Yes

Do you have any bloodbourne pathogens, transmittable diseases or recent illnesses? (It's okay if you do, we just want to know for our and other's safety).

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Influence *

I am not under the influence of alcohol or drugs, and I am voluntarily submitting to be tattooed by the Artist without duress or coercion.

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Photography

I release all rights to any photographs taken of me and the tattoo and give consent in advance to their reproduction in print or electronic form. (If you do not tick this provision, please advise your Artist).

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Consent

I acknowledge by signing this waiver that I have been given the opportunity to ask any and all questions which I might have about the obtaining of a tattoo or piercing by Midwest Tattoo LLC, DBA Rising Phoenix Tattoo and that all my questions have been answered to my full and total satisfaction. I specifically acknowledge that I have been advised of the facts and matters set forth below and agree as follows:

I acknowledge that infection is always possible as a result of obtaining a tattoo or piercing particularly but not limited to the event that I do not take proper care of my tattoo or piercing.
I acknowledge receipt of verbal and/or written instructions advising me of the proper care of my tattoo or piercing and further recognize the absolute necessity for following those instructions.
I realize that variations in color and design may exist between any tattoo selected by me and as ultimately applied to my body.
I acknowledge that a tattoo or piercing 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 the tattoo or piercing.
I acknowledge that I have truthfully represented to the employees, agent, subcontractors, and representatives of Midwest Tattoo LLC, DBA Rising Phoenix Tattoo that I am of legal age according to Illinois Criminal Code to obtain services performed at Rising Phoenix Tattoo.
I agree to release and forever discharge and hold harmless Midwest Tattoo LLC, DBA Rising Phoenix Tattoo employees, agents, subcontractors and representatives from any and all claims, damages, or legal actions arising from or connected in any way with my tattoo or piercing or the procedures and conduct used to apply my tattoo or piercing.
I understand that Midwest Tattoo LLC, DBA Rising Phoenix Tattoo, its employees, agents, representatives or subcontractors have made no representation about and assume no responsibility for any and all spelling and grammar mistakes in any language; I also understand that tattoos, over time, may fade, and or fall out, specifically when located on hands, fingers, feet, and toes.
I agree whether the information I provide is truthful, or if my signature is or is not applied, that I agree to the terms set forth in the agreement.
I acknowledge that I have seen a physician and have been deemed medically able to get a tattoo or a piercing.
I acknowledge that I have read both sides of this form.
After receiving a tattoo or piercing, it is recommended that you do not drive if you are feeling dizzy, faint, or lightheaded.

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How did you hear about us?

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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.

Signature

Clear

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