Tattoo Waiver and Release Form Software

BACKSTAGE TATTOO CONSENT FORM

4472 PALISADES CENTER DRIVE WEST NYACK, NY 10994 – 845.727.4909

CONSENT, RELEASE AND WAIVER OF ALL CLAIMS

I hereby acknowledge to obtain a tattoo and have been given full opportunity to ask any and all questions I might have about obtaining tattoo from Backstage, and all my questions have been answered to my full and total satisfaction.

I specifically acknowledge that I have been advised of the following:

1.Obtaining this tattoo is my choice alone and will result a permanent change to my appearance, and that no representation has been made to me as to the ability to later restore the skin involved in this tattoo to its pre-tattoo conditions.

2.It is not reasonably possible for the tattoo artist to determine whether I have an allergic reaction to the tattoo or process in the tattoo and further acknowledge that such a reaction is possible.

3.Intenze and starbrite colors are distributed by Dermagraphics Mfg & Supply INC. The ingredients of these dispersions are represented to be non-toxic by the manufacture; however no representation is made regarding their use as an approved tattoo ink.

4.I will be tattooed using appropriate instruments and sterilization techniques

5.I have been advised of all the procedures necessary to promote satisfactory healing of my tattoo

6.I must consult a health care provider for: unexpected redness, tenderness, swelling , unexpected drainage at the site of the piercing, any rash or a fever within (2) hours of the body art procedure

7.Infection is always a possible result of obtaining a tattoo, and I agree to follow all the instructions concerning the care of my tattoo while it is healing. However, if infection will occurs as a result of this tattoo, I release and discharge the business Back Stage, its owners and employees, and the tattoo artist, from all liability.

I represent to my tattoo artist that

The following conditions may increase health risks associated with receiving body art:

History of Diabetes
History of Hemophilia (bleeding)
History of Skin diseases, lesions, or skin sensitivities to soaps, disinfectants etc
History of allergies or adverse reactions to pigments, dyes, or other sensitivities
History of epilepsy, seizures, fainting, or narcolepsy
Use of medications such as anticoagulants, (Coumadin) which thin the blood and/or interfere with blood clotting
Hepatitis, HIV or any other communicable disease

Please select your condition below *

I do not have Diabetes

I have Diabetes, and understand that my conditions may hamper the healing process

Please select at least one choice above.

Date *

Please enter valid date.

Full Name: *

Please enter your full name.

Address * Please enter your name.

Date of Birth: *

Please enter valid date.

Phone Number: * Please enter your phone number.

Email: Please enter your email.

I am not pregnant or nursing

I do not have Epilepsy or Hemophilia

I do not have heart conditions or take any medications such as anticoagulants that thin my blood

I do not have any medical or skin conditions such as, but not limited to, Keloids, Hypertrophy scarring, Psoriasis, Lesions or open wounds at the site of the tattoo

I do not have HIV, Hepatitis or any other communicable disease

I am at least 18 years of age

Description of Tattoo: Please enter your answer here.

Location of Tattoo: Please enter your answer here.

Signature

I, the customer, hereby release and discharge the business Backstage(DAVANTI INC) and its owners, corporate officers, employees, assignees, apprentices, subcontractors, landlords, successors and the city of West Nyack, from all liabilities to myself, my spouse, my legal representative, heirs and I assign for any and all losses or damages related to any tattoo services received by the customer. * Please click the yellow area and provide your initials here.

Signature

I hereby release all rights, claims and actions related to the tattoo, the placement of the tattoo and the design. * Please click the yellow area and provide your initials here.

Now that you have gotten your new tattoo, Back Stage would like to thank you for choosing our parlor. It’s up to you now to make sure you properly take care of your tattoo.

Here are some helpful instructions:

• 1. Leave the bandage on for a few hours.

2. Wash with warm water and anti-bacterial soap & pat dry.

3. Apply a non-petroleum jelly based anti-bacterial cream (H2Ocean, Tattoo Goo) 2 – 5 times a day for 2 weeks.

For at least 2 weeks:

1. Do not pick scabs.

2. Do not submerge in water.

3. Do not expose to direct sunlight.

The tattoo may form a layer of dry skin or a light scab in a few days. This will flak off by itself in time. Do not panic… this is normal. If an infection occurs, please consult a physician.

CONSULT HEALTH CARE PROVIDER FOR:

1. Unexpected redness, tenderness or swelling at the site of the piercing

2. Rash

3. Unexpected drainage at or from the site of the piercing

4. Fever within 24 hours of the piercing

Tattoos & Piercings are Final Sale and Non Refundable and cannot be returned for store credit.

Emergency Contact Person: Please enter your name.

Emergency Contact Person's Phone Number: Please enter your phone number.

Are you experiencing other flu like symptoms, such as gastrointestinal upset, headache, or fatigue? *

Yes

Please select at least one choice above.

Do you have Heart disease, Lung disease, Kidney disease, Diabetes, or any Auto-Immune Disorders? *

Yes

Please select at least one choice above.

I understand that by entering this facility and having this procedure (tattoo/body piercing) performed, there is a risk of contracting Covid-19.

Customer's Signature *

Click to sign

Please sign here.

Artist Name * Please enter your name.

Artist signature *

Click to sign

Please sign here.

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