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Unlucky Kat Tattoo
General Procedure Consent Form
Please fill out the following health declaration form in order to participate in our activity. Submissions are valid up to 24 hours prior to the activity.
First Name
Last Name
Birthday
Drivers License # or State ID #
Address
Email
I am not under the influence of alcohol or drugs
I acknowledge that I am not pregnant.
I acknowledge that I am free of communicable disease.
I acknowledge that I have truthfully represented to the associates, agents and representatives of Unlucky Kat Tattoo that I am over eighteen (18) years of age.
I acknowledge that infection is always possible as a result of obtaining a tattoo/piercing particularly in that event that I do not take proper care of my tattoo/piercing, and I have been advised of the signs and symptoms of infection that indicate a need to seek medical care.
I acknowledge that there is a chance I might feel lightheaded, dizzy during or after being tattooed. I agree to immediately notify the practitioner in the event I feel lightheaded, dizzy and/or faint before, during or after the procedure.
I agree to follow all instructions concerning the care of my tattoo/piercing, and that any re-piercing or touch ups needed because of my own negligence will be done at my own expense.
I acknowledge that the obtaining of my tattoo/piercing is my choice alone and I consent to the application of the tattoo and to any actions or conduct of the associates, agents or representatives of Unlucky Kat Tattoo that are reasonable necessary to perform the tattoo/piercing procedure.
I agree to release and forever discharge and forever hold harmless Unlucky Kat Tattoo and its associates, agents officers and shareholders from any and all claims, damages, or legal actions arising from or connected in any way with my tattoo/piercing or the procedures and conduct used to apply my tattoo/piercing and any and all tattoos/piercings applied by Unlucky Kat Tattoo and its associates, agents and representatives in the future.
Are you experiencing any flu symptoms?
No
Yes
Your Signature
Clear
Date
Initials
I confirm that the information given in this form is true, and have been fully informed of the risks of tattooing/piercing including but not limited to infection, scarring, difficulties in detecting melanoma, and allergic reactions to tattoo pigment, latex gloves, and antibiotics. Having been informed of the potential risks associated with getting a tattoo/piercing, I still wish to proceed with tattoo/piercing application and I assume any and all risks that may arise from tattooing/piercing.
Submit
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