Tattoo | BUELISTIC

TATTOOS

NEED MORE INK?

All scheduled appointments are registered in Pacific Daylight Time
Currently based in Los Angeles, California

Ink Therapy Consultation
Service Information
1 hr
100 US dollars

CONSENT FORM

Tattoo Consent Form & Medical Questionnaire

In Compliance with State & County Law, It is required to complete this form in order to complete your tattoo appointment

First Name

Last Name

Date of Birth

Phone

Address (Include Street Address, City, State/Province, Postal)

CONSENT & MEDICAL QUESTIONAIRE I HAVE READ, UNDERSTOOD & AGREED TO THE FOLLOWING:

I hereby certify that to the best of my knowledge this information is correct

All questions have been answered to my satisfaction

A brief description of the type of procedure and the loaction of procedure has been provided by the artist

I undertstand that the tattoo I am receiiving is permanent, and administered byt penetrating the skin with pigment

I certify that I am at least 18 years of age

I am not under the influence of ALCOHOL or DRUGS, and am voluntarily submitting to be tattooed without duress or coercion

I understand that there is a possibility of an allergic reaction

I understand that there is a possibility of an infection

I agree to follow all instructionconcerning te care of my tattoo, and that any touch ups neede due to my own negligence will be done at my own expense

Variations in color and design may exist between the tattoo art I have selected and the actual tattoo when it is applied to my body. I also understand that over time colors and the clarity of my tattoo will fade due to unprotected exposure to the sun and the naturally occuring dispersion of pigment under the skin

I understand that the FDA has no approved of any : inks, dyes, or pigments and that health effects are unknown.

I have read and will will agree to follow aftercare instructions pertainingt the body art procedure

I understand that there is a chance that I many feel light-headed and/or dizzy during or after being tattooed

I understand that my artist will complete my desired procedure in a private studio and is a registered current licesed practicioner under California State Law

CLIENT QUESTIONAIRE:(Please check all conditions that apply to you listed below)

None

Diabetes

Hemophilia

Heart Condition

Herpes at the sight

Epilespsy

Eczema/Psoriasis

Blood Thinners

Pregnant/Nursing

Skin Conditions

Scarring/Keloiding

Hepatitis B/C

Latex Allergy

Diabetex or Antibiotics

Blood pathogens risks, including but not limited to HIV & AIDS

History of medication usevor are using medication (includingbeing prerscribed antibiotics prior to dental or surgical procedures). Rev.9/2018 Californa Health & Safety Code 119303

PLEASE CHECK THE BOXES PROVIDED AFTER READING SHOW THAT YOU UNDERSTAND EACH PROVISION. FEEL FREE TO ASK ANY QUESTIONS REGARDING THIS WAIVER. In consideration of receiving a tattoo from this facility, including its artist(s), Associate(s), apprentice(s), agent(s), or any employee(s) (hereinafter referred to as the "Studio") I agree to the following:

The tattoo studio has given me the full Opportunity to ask any questions about the procedure and applicatin of my tattoo and all of my questions if any, hace been answered to my total satisfaction

The tattoo studio has given me instructions on the careof my tattoo while its healing. i understand and will follow them. I acknowledge that it is possible that the tattoo can become infected, particularly if I do not follow te instructions given to me. If any touch-up work is needed due to my own negligence, I agree that the work will be done at my own expense

I am not under the influence of any alcohol or drugs, and i]I am voluntarily submitting to be tattooed by the tattoo studio without duress or coercion

I don't suffer from diabetes, epilepsy, hemophilia, heart conditions, nor ingest blood thinning medication. No medical or skin condition that may interfere with the procedure, application or healing of the tattoo. I have taken the prescribed preventative regimen of antibiotics that is required by my doctor in advance of any invasive procedure such as tattooing

I am not pregnant or nursing. I do not have a mental impairment that may affect my judgment in getting the Tattoo

The Studio is not responsible for the meaning or spelling of the symbo or text that I hav provided to them or chosen from the flash (design) sheets

Variations in color and Design may exist between the art I have selected and the actua tattoo when it is applied to my body. I also understand that over time, te colors and clarity of my tattoo will fade due to unprotected exposure to the sun and the naturally occurring dispersions of pigment under the skin

A tattoo is a permanent change to my appearance and can only be removed by laser or surgical means, which can be disfiguring and/or costly and which in all likelihood will not result in restoration of skin to its exact appearance before being tattooed

Tattoo inks, dyes, and pigments, have not been approved by the FDA. Health consequences to these are unknown

I release the right to any photographs taken of me and the tattoo and give consent in advance to their reproduction in print or electronic form. (For assurance, if you do not check the box of this provision, please inform the artist and studio NOT to take any pictures of you and your completed tattoo)

I agree that the Studio has a No Refund policy on tattoos or retail sales and I will not ask for a refund for any reason whatsoever

I agree to reimburse the studio and artists for any fees and costs incurred in any legal action I bring against the Studio and Artist and in which either the Artist of the Studio is the prevailing party.

I agree that the courts oflocated in the county of Alameda within the State of California shall have jurisdiction and venue over me and shall have exclusive jurisdiction for the purposes of litigating any disput arising out of or related to this agreement

I acknowledge that i have been given adequate opportunity to read and understand this document that it was not presented to me at the last minute and grasp that I am signing a legal contract waiving certain rights to recover damages against the studio and artist. if any provision, section, subsection, clause or phase of this release is found unenforceable/invalid, that portion will be severed.

I have been fully informed of the inherent risks associated with getting a tattoo. Therefore, I fully understand that these risks, known and unknown, can lead to injury including but not limited to: infection, scarring, difficulties in detection of melenoma and allergic reactions to tattoo pigment, latex gloves and/or soap. Having been informed of the potential risks associated with getting a tattoo. I wish to proceed wth the tattoo procedure and application and freely acceptnd expressly assume any and all risks that may arrive from tattooing

I waive and release to the fullest extent permitted by law any person of the Facility from all liabity whatsoever, including but not limited to, any and all claims or causes of action that I, my estate, heirs, executors, or assigns may have for personal injury or otherwise, including any direct and/or consequential damaes, which result or arise from the procedure and application of my tattoo, whether caused by the negligence of fault of either the Studio, or otherwise

I declare that the info I’ve provided is accurate & complete

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TATTOOS

NEED MORE INK?

All scheduled appointments are registered in Pacific Daylight Time Currently based in Los Angeles, California

Ink Therapy Consultation

CONSENT FORM

Tattoo Consent Form & Medical Questionnaire

All scheduled appointments are registered in Pacific Daylight Time
Currently based in Los Angeles, California