tattoo waiver online form - WaiverElectronic

Keipsake Body Emporium Tattoo consent/liability release form

PLEASE READ CAREFULLY AND PROVIDE REQUESTED INFORMATION

Here at KeipSake Body Emporium, we strive to provide the most sterile and comfortable conditions possible. We gladly provide aftercare instructions for your new tattoo or piercing. You are responsible for the aftercare procedure.

_____ If you are a hemophiliac, diabetic, or have any illness that would effect or suppresses you immune system KeipSake Body Emporium is not liable for the healing time or condition of your tattoo or body piercing.

_____ If you have made the decision to get tattooed or pierced under the influence of drugs or alcohol or peer pressure KeipSake Body Emporium is not responsible for your regret or emotional duress in the future. I agree that any touch-up work needed due to my own negligence will be done of my own expense. I understand that if my skin color is dark, the colors will not appear as bright as it would on light skin.

_____ I agree not to hold KeipSake Body Emporium or any representatives liable for infection or injury due to improper aftercare of any body modification. You are responsible for the aftercare procedure.

_____ I hereby release KeipSake Body Emporium from all manners of liabilities, claims, actions, demands, or death, in law or in equity, which I or my heirs might have now or hereafter by reason of complying with my request for body modification, regardless of fault.

_____ I agree that I or my heirs, assigns, and legal representatives to hold KeipSake Body Emporium harmless from all other costs and expenses which might arise from my decision to have body modification done by KeipSake Body Emporium.

_____ I agree to pay for any and all damages and injuries to any and all persons and property belonging to or by operation of law caused by or resulting from my decision to have body modification work done by KeipSake Body Emporium.

_____ I agree to leave the premises of KeipSake Body Emporium or any other establishment where KeipSake Body Emporium is engaged in business, promptly upon request for any reason what-so-ever by any agent or employee of KeipSake Body Emporium.

_____ I agree that these waivers also pertain to and are designed to any and all establishments where KeipSake Body Emporium conducts business.

_____ I recognize that the suggestions and aftercare given tome by KeipSake Body Emporium employees or agents are based upon their experience in this field and current industry standards. Employees or agents of KeipSake Body Emporium are not doctors, and their suggestions, whether written or verbal, stated or implied, are not meant to be taken as medical advice. In the event of a serious medical concern I should see my physician.

I declare under penalty of perjury that the above is true, current, and correct.

By checking this box, I agree to the statements above * Please check it here.

First name: * Please enter your name.

last name: * Please enter your name.

Date of Birth: *

Please enter valid date.

age * Please enter your answer here.

Gender: * Please select one here.

race * Please enter your answer here.

Phone number: * Please enter your phone number.

Email: Please enter your email.

Please fill in Address: *

Please enter address.

EMERGENCY Contact/ Medical Information

What hospital would you like to use incase of a medical emergangy? *

Shands Lake Shore

Lake City Medical

Please select at least one choice above.

Emercangy Contact Name * Please enter your answer here.

Emergancy Contact Number * Please enter your answer here.

Do you have a history of bleeding disorders? *

yes

Please select at least one choice above.

Can our aprentice prep for your procedure? *

yes

Please select at least one choice above.

Have you made this decicition under your own free will? *

yes

Please select at least one choice above.

Are you under the age of 18? if so do you have noterized written consent? *

yes

Please select at least one choice above.

Are you under the influence of excessive alcohol, excessive caffeine (coffee, energy drinks) or drugs? *

yes

Please select at least one choice above.

Are you a hemophiliac (bleeder), diabetic, epileptic, hepatitis, or have any illness that suppresses the immune system? *

yes hemophiliac (bleeder)

yes diabetic

yes epileptic

yes hepatitis

Please select at least one choice above.

Have you been exposed to any illness and/or infections in the last six (6) months, including staphylococcus? *

yes

Please select at least one choice above.

Have you received a piercing or tattoo in the last 90 (ninety) days? *

yes

Please select at least one choice above.

Are you prone to boils, rashes, or cold sores? *

yes.

Please select at least one choice above.

Are you on any medication or vitamin supplement that may thin your blood, such as aspirin, ibuprofin, or other NSAIDs? *

yes

Please select at least one choice above.

If you are a female, are you pregnant or nursing? *

yes

Please select at least one choice above.

Have you eaten in the last two (2) hours before this procedure? *

yes

Please select at least one choice above.

Do you have any allergies, such as latex, zinc, almonds, lidocaine, iodine, lavender? *

yes

Please select at least one choice above.

Please list any other medical conditions that may affect the procedure: * Please enter your answer here.

PLEASE NOTE: The following conditions could effect and result in color loss: menstrual cycle, menopause, hormone replacement, or steroids. In addition, any medical procedures, such as surgery, preformed during the healing of today’s procedure could increase risk infection or illness.

What procedure are you here for today? *

tattoo

piercing

semi-permenatnt makeup

pigment corection

tattoo removal

scar sofening

collegen renewal

Please select at least one choice above.

Placement * Please enter your answer here.

Approx size * Please enter your answer here.

Description * Please enter your answer here.

Price * Please enter your answer here.

Technician * Please enter your answer here.

Prior to my procedure, I will receive verbal and written information about the following and discussed it with my artist or the establishment operator: 1) a brief description of my tattoo or piercing procedure; 2) any precautions for me to take before my tattoo or piercing; 3) a description of the risks and possible consequences of body modification services; 4) instructions for care and restrictions following my body modification; and 5) restrictions against tattooing or piercing minors.

FOR MARKETING AND PROMOTIONAL PURPOSES:

I grant KeipSake Body Emporium or any members or representatives of KeipSake Body Emporium permission to use photos and/or videos of my procedure and end result for marketing and promotional purposes.

KeipSake Body Emporium must obtain a written, notarized consent statement before tattooing and/or piercing a minor. If the minor is under the age of 16, the minor MUST ALSO be accompanied by a parent or legal guardian during any tattoo and/or piercing.

All customer records must be kept for at least two (2) years.

By checking this box, I agree to all statements and information stated above * Please check it here.

Please Enter Date *

Please enter valid date.

Your signature *

Click to sign

Please sign here.

Your name * Please enter your answer here.

Tattoo waiver online forms are well-known in the tattoo business.