Consent Form "*" indicates required fields I acknowledge I am NOT pregnant and I am not nursing at this time.* I acknowledge I am NOT pregnant and I am not nursing at this time.*I acknowledge that I am not under the influence of alcohol or drugs at this time.* I acknowledge that I am not under the influence of alcohol or drugs at this time.*I am free from all communicable diseases. I do not have: Epilepsy, Jaundice, Hepatitis, AIDS/HIV or Hemophilia. I will let my artist know if I have issues with scarring or keloiding.* I am free from all communicable diseases. I do not have: Epilepsy, Jaundice, Hepatitis, AIDS/HIV or Hemophilia. I will let my artist know if I have issues with scarring or keloiding.*I acknowledge that I have truthfully represented that I am over 18 (eighteen) years old with proper identification.* I acknowledge that I have truthfully represented that I am over 18 (eighteen) years old with proper identification.*I acknowledge that it is not reasonably possible for the tattoo artist to determine whether I may have an allergic reaction to the dyes, pigments or processes used in my tattoo, and I agree to accept that this risk is a possibility.* I acknowledge that it is not reasonably possible for the tattoo artist to determine whether I may have an allergic reaction to the dyes, pigments or processes used in my tattoo, and I agree to accept that this risk is a possibility.*I acknowledge that infections are always a possibility as a result of obtaining a tattoo, particularly in the event that I do not properly take care of my tattoo.* I acknowledge that infections are always a possibility as a result of obtaining a tattoo, particularly in the event that I do not properly take care of my tattoo.*I acknowledge that variation in color and design may exist between any tattoo selected by me and as ultimately applied to my body.* I acknowledge that variation in color and design may exist between any tattoo selected by me and as ultimately applied to my body.*I acknowledge that the obtaining of my tattoo is by my choice alone and I consent to the application of the tattoo and to any actions or conduct of the tattoo artist, reasonably necessary to perform the tattoo procedure.* I acknowledge that the obtaining of my tattoo is by my choice alone and I consent to the application of the tattoo and to any actions or conduct of the tattoo artist, reasonably necessary to perform the tattoo procedure.*I agree to release and forever discharge and hold harmless, Black Floral Inks and its agents, employees, representatives, officers and shareholders from any and all claims, damages or legal actions arising from or connected in any way with my tattoo or procedures and conduct used to apply my tattoo.* I agree to release and forever discharge and hold harmless, Black Floral Inks and its agents, employees, representatives, officers and shareholders from any and all claims, damages or legal actions arising from or connected in any way with my tattoo or procedures and conduct used to apply my tattoo.*I agree to give the tattoo artist consent to publish any and all photos of my tattoo(s).* I agree to give the tattoo artist consent to publish any and all photos of my tattoo(s).*I acknowledge that all payments, both deposits and payments for services the day of the appointment, are non-refundable.* I acknowledge that all payments, both deposits and payments for services the day of the appointment, are non-refundable.*I acknowledge that my initial deposit allows for two rescheduled appointments. If I need to reschedule more than twice, an additional deposit will be necessary.* I acknowledge that my initial deposit allows for two rescheduled appointments. If I need to reschedule more than twice, an additional deposit will be necessary.*To my knowledge, I do not have any physical, mental or medical impairment or disability which might affect my well-being as a direct or indirect result of my decision to have a tattoo.* To my knowledge, I do not have any physical, mental or medical impairment or disability which might affect my well-being as a direct or indirect result of my decision to have a tattoo.**If an adverse reaction or infection develops at the site of your tattoo, contact your personal physician for treatment and report to SNHD Special Programs at (702) 759-0677.* *If an adverse reaction or infection develops at the site of your tattoo, contact your personal physician for treatment and report to SNHD Special Programs at (702) 759-0677.*Name* First Last Email* Date of Birth* MM slash DD slash YYYY Picture of Driver License or IDMax. file size: 2 GB.Signature*EmailThis field is for validation purposes and should be left unchanged.
