Forms

Name

Age

Preferred Pronouns (optional)

Phone

City

Postal / Zip Code

Emergency Contact Name (optional)

Emergency Contact Phone Number (optional)

I acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions which I might have about the obtaining of a tattoo and that all of my questions have been answered to my full satisfaction. I specifically acknowledge I have been advised of the facts and matters set forth below and I agree as follows:

Please check to acknowledge:*

I have advised my tattoo artist of any condition that might affect the healing of this tattoo.

I am not pregnant or nursing.

I am not under the influence of alcohol or drugs.

I do not have medical or skin conditions such as, but not limited to: acne, scarring (keloid) eczema, psoriasis, freckles, moles or sunburn in the area to be tattooed that may interfere with said tattoo. If I have any type of infection or rash on my body I will advise my tattooer.

I acknowledge it is not reasonably possible for my tattoo artist to determine whether I might have an allergic reaction to the pigments or processes used in my tattoo, and I agree to accept the risk that such a reaction is possible. I acknowledge that infection is always possible as a result of the obtaining of a tattoo, particularly in the event that I do not take proper care of my tattoo. I have received aftercare instructions and I agree to follow them while my tattoo is healing. I agree that any touch-up work needed, due to my own negligence, will be done at my own expense.

I realize that variations in color and design may exist between any tattoo as selected by me and as ultimately applied to my body. I understand that if my skin color is dark, the colors will not appear as bright as they do on light skin.

I understand that it I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my tattoo.

II acknowledge that a tattoo is a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove my tattoo. To my knowledge, I do not have a 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.

I acknowledge I am over the age of eighteen (18) and that I have truthfully represented to my tattooer or any representative of BALDUCCHIARTE inc. that the obtaining of a tattoo is by my choice alone. I consent to the application of the tattoo and to any actions or conduct of the application or the tattoo and to any actions or conduct of the
representatives and employees of
Valerie Rapne inc. reasonably necessary to perform the tattoo procedure.

I acknowledge and agree to following any and all instructions provided to me regarding the maintenance of a sanitary environment during the tattoo process.

I agree to immediately notify my tattooer if I feel lightheaded, dizzy and/or faint before, during or after the procedure. Failure to do so releases the tattoo artist or any representative of Valerie Rapne inc. of any and all responsibility.

I acknowledge and understand that the artist's suggestions and advice are not to be confused with medical advice.

I have answered all of the preceding questions truthfully and am fully aware of and take full responsibility for the tattoo process, the healing and daily aftercare.

I wish to proceed with the tattoo and freely accept the risks that may arise from it.I give permission to use photos of me/my tattoo for the purpose of marketing. My pictures may appear in print or online.

MEDICAL HISTORY
QUESTIONNAIRE

Please check if applicable:*

Hemophilias

Scarring/Keloiding

Pregnant/Nursing.

Allergic to Lidocaine

Allergic to Latex

Eczema/Psoriasis

Skin Conditions

Hepatitis B/C

Blood pathogens risks, including but not

limited to AIDS & HIV

Diabetes

Epilepsy

Asthma

Faintness/Dizzyness

Heart Condition

N/A

Other

Photo of ID

signature

I confirm that I have read and agree to all terms in this form, the Terms of Service, Privacy Policy, and Tattoo Consent Form. All provided information is accurate and truthful. My actions constitute an electronic signature equivalent to a handwritten one.