Tattoo Release Form Software - WaiverElectronic

Dark Amor Tattoo & Piercing

You have requested a tattoo/piercing treatment that involves minor breakage to the skin surface with a needle and this process may complicate some conditions. Please read the following information carefully and if any of these conditions apply to you please discuss them with your operative prior to having your tattoo/piercing.

Name: *

Please enter your full name.

Address: *

Please enter address.

Phone: * Please enter your phone number.

Date of Birth: *

Please enter valid date.

Age: * Please enter your answer here.

Eczema/Psoriasis/Acne/Cellulitis or Other Skin Condition. * Please enter your answer here.

Heart Disorder. Yes or No, If YES, Please State. * Please enter your answer here.

High/Low Blood Pressure. Yes or No, If YES, Please State. * Please enter your answer here.

Haemophilia or Other Bleeding Disorder. Yes or No, If YES, Please State. * Please enter your answer here.

Epilepsy. Yes or No, If YES, Please State. * Please enter your answer here.

Diabetes. Yes or No, If YES, Please State. * Please enter your answer here.

Hepatitis A,B,C. Yes or No, If YES, Please State. * Please enter your answer here.

HIV Infection. Yes or No, If YES, Please State. * Please enter your answer here.

Pregnant or Nursing Mother. Yes or No, If YES, Please State. * Please enter your answer here.

Known Allergies. Yes or No, If YES, Please State. * Please enter your answer here.

On Any Medication. Yes or No, If YES, Please State. * Please enter your answer here.

Any Other Condition Not Listed Please enter your answer here.

Please note that treatment will not be undertaken if under the influence of drugs or alcohol. I know acknowledge by signing this agreement that I have been given full opportunity to ask any questions which I might have about obtaining treatment and that all questions have been answered to my satisfaction. I acknowledge that it is not reasonably possible to determine whether I might have an allergic reaction to pigments or jewellery used and I agree to accept the risk that such is possible. I acknowledge that infection is always possible as a result of obtaining a tattoo/piercing, particularly in the event I do not take proper care of my tattoo/piercing and I agree to all the instructions concerning my aftercare.

This is to certify that I, the above named, give my permission to be tattoo/pierced.

Signed: *

Click to sign

Please sign here.

Date *

Please enter valid date.

Counter Signed (If Required by Piercer)

Click to sign

Please sign here.

Date

Please enter valid date.

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To be Complete by Operative:

Name: * Please enter your name.

Position of Treatment: * Please enter your answer here.

ID Shown: * Please enter your answer here.

The sign of time and efficiency - electronic tattoo waiver

﻿Dark Amor Tattoo & Piercing﻿

Dark Amor Tattoo & Piercing