MEDICAL HISTORY AND TATTOO CONSENT AND RELEASE FORM
ART OF THE HEART TATTOOS • 237 WEST MAIN AVE. MORGAN HILL, CA. 95037 • (408) 759-8282 •
THIS FORM MUST BE COMPLETED IN FULL ONLINE BEFORE YOUR APPOINTMENT. IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT US BEFORE YOUR APPOINTMENT. THANK YOU.
Please check if you have any of the following:
Faint or Dizzy
Cardiac Valve Disease
Are you currently taking any medication? Please list:
Are there risk factors for bloodborne pathogen exposure?
Are there any other known MEDICAL CONDITIONS or CONTAGIOUS DISEASES that may affect your TATTOO procedure? Please list any not mentioned above:
Sec. B11-503. - Body art disclosure statements, client health history, and informed consent.
Notice: Tattoo inks, dyes, and pigments have not been approved by the federal Food and Drug Administration and that the health consequences of using these products are unknown.
Signs and symptoms of infection, including, but not limited to, redness, swelling, tenderness of the procedure site, red streaks going from the procedure site towards the heart, elevated body temperature, or purulent drainage from the procedure site.
Information on the care of the procedure site:
* After 1 hour. Remove the bandage gently and wash with warm water and mild soap (Dial). Do not Re-bandage
* Apply a thin film of After Ink, 2-3 times a daily, for the next 3 days. After 3 days use a non-scented lotion until the skin returns to its pre-tattooed condition.
* Stay out of sunlight and tanning booths until the tattoo is healed, at least 2-4 weeks.
* Do not soak the tattoo in a tub, sauna, Jacuzzi, or go swimming while your new tattoo is healing. Showers are fine!
* Do not rub or pick the treated area while it is healing. Loss of color and/or infection could occur.
* Extreme sun and exposure over the years can and will fade your tattoo. This can be minimized by using a strong sunscreen, at least SPF25.
* Your tattoo should heal in 2-4 weeks. Consult a physician if any signs or symptoms develop such as the following: extreme redness at sight, green/yellow discharge (foul-smelling), and/or fever.
If you have any questions or concerns please give us a call!
Restrictions on physical activities such as: No recreational water activities for one month, no gardening until the tattoo is completely healed and no contact with any animals that may have been outdoors.
Call a physician if any of the addressed signs and symptoms appear or for any other reason related to the body art procedure.
Please check any conditions listed below that apply to you: We are required by law to provide you with the following information:
Please read each statement carefully before signing below!
* I hereby certify that to the best of my knowledge this information is correct.
* All Questions have been answered to my satisfaction and I have been given written and verbal aftercare instructions for the Body Artwork I am about to receive.
* I agree the said TATTOO is correctly drawn to my specifications.
* I understand that the said TATTOO is PERMANENT.
* This is to certify that I am at LEAST 18 YEARS OF AGE.
* I am not under the influence of ALCOHOL OR DRUGS.
* I understand there is a possibility of an allergic reaction.
* I understand there is a possibility of an infection.
* I agree to allow for ARTIST INTERPRETATION.
* I agree to follow all instructions concerning the care of my TATTOO and that any touch-ups or repairs that may become needed due to my own negligence will be at my own expense.
* I understand that there is a chance I might feel lightheaded, dizzy and/or faint due to my decision to receive a TATTOO.
* I agree to IMMEDIATELY notify the artist in the event I feel lightheaded, dizzy and/or faint before, during, or after the procedure. * Failure to do so releases ART OF THE HEART TATTOOS and ARTISTS of all responsibility.
* By signing this form I hereby release ART OF THE HEART TATTOOS and ARTISTS of all responsibility for the said TATTOO.
* If any accidents occur in the business of, Art of the Heart Tattoos (237 West Main Ave. Morgan Hill CA. 95037) that result in any bodily injury or damages, by signing this form you are waiving all rights to any legal actions against any employees of Art of the Heart Tattoos and the owners of Art of the Heart Tattoos and the LLC. Of Art of the Heart Tattoos.
By signing this form, I have read and agreed to all listed conditions and terms and have been given verbal post-procedure instructions.
Is this a touch-up?
How did you hear about us?
Approximate tattoo cost for each session: $
Emergency Contact Name
Emergency Contact Phone #
NO REFUNDS, ALL SALES ARE FINAL!
I acknowledge and agree that this Agreement covers and is intended to release, Art of the Heart Tattoo, artists, property owner, owners, officers, managers, subsidiaries, affiliates, volunteers, participants, employees, and all other persons or entities acting in any capacity on their respective or collective behalf.
I understand that this agreement extends forever into the future and will have full force and legal effect each and every time I visit Art of the Heart Tattoos, whether at the current location or any other location or facility.
PHOTO RELEASE: By entering Art of the Heart Tattoo, I hereby grant Art of the Heart tattoo and Artist, on behalf of myself, the irrevocable right and permission to photograph and/or record me in connection with Art of the Heart Tattoos and to use the photograph and/or recording for promotional purposes. I waive any right to inspect or approve the use of the photograph and/or recording, and acknowledge and agree that the rights granted to this release are without compensation of any kind.
ASSUMPTION OF RISK: I acknowledge that If such minor accompanies a client, Art of the Heart Tattoos, artist and owners are not responsible for anything that may occur and you agree to release all liability towards, Art of the Heart Tattoos, all Artist and owners and property owner.
RELEASE OF LIABILITY. I hereby irrevocably and unconditionally release, waive, relinquish, discharge from liability and covenant not to sue ART OF THE HEART, Artist, Owners and/or Property Owners from any and all claims, demands, rights, actions, suits, causes of action, obligations, debts, costs, losses, charges, expenses, damages, judgments and liabilities, of whatever kind or nature, in law, equity or otherwise, whether now known or unknown, suspected or unsuspected, and whether or not concealed or hidden, related to or arising, directly or indirectly, from my or my child(ren)/ward(s)’ while in Art of the Heart Tattoo’s use of equipment, services and activities, including without limitation, any claim for negligence and/or recklessness, arising from property damage, personal or bodily injury, emotional injury, illness, or death to the maximum extent allowed by law.
By clicking "I understand", you acknowledge that you have read and agreed to everything above. You give Art of the Heart Tattoo permission to post your picture and you have received aftercare instructions.
A copy of your responses will be emailed to the address you provided.
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