In consideration of receiving a TATTOO from

at 444SVT together with its personnel, apprentices and independent agents or guests of the “facility” in the State of California, I AGREE TO THE FOLLOWING:

That I,

have been informed of the inherent risks associated with getting a tattoo procedure. I understand that these risks, known and unknown, can lead to injury, including but not limited to infection, scarring, nerve damage, difficulties in detecting melanoma, allergic reactions to tattoo pigments, latex gloves and/or soap. Tattoo procedures may cause swelling, bruising, discomfort, bleeding, and pain. Tattoo procedures may cause an allergic reaction and may also cause irreversible changes to the human body. Donating blood may be prohibited after receiving a procedure. Having been informed of the potential risks associated with getting a tattoo procedure, I still wish to proceed with the tattoo application and I freely accept and expressly assume any and all risks that may arise from this action.

I understand that tattoo procedures are 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 likely will not result in the restoration of my skin to its exact appearance before the procedure.

TO WAIVE AND RELEASE to the fullest extent permitted by law each of the practitioners and the “facility” from all liability whatsoever, for 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 damages, which result or arise from the application of my tattoo procedure, whether caused by the negligence or fault of either the practitioner, facility, or otherwise.

I agree to reimburse the practitioner and the facility for any/all attorneys’ fees and costs incurred in any legal action I bring against either the practitioner or the facility and in which either the practitioner or the facility is the prevailing party. I agree that the courts shall have personal jurisdiction and venue over me and shall have exclusive jurisdiction for the purpose of litigating any dispute arising out of or related to this agreement.

Neither the practitioner nor the facility is responsible for the meaning or spelling of symbols or text that I provide to them, or that is chosen from the example design sheets or hand-drawn and designed by my direction.

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

The practitioner or the facility representative has given me written and verbal suggested aftercare instructions for the care of my tattoo procedure while it’s healing and I understand and will follow them. I acknowledge that it is possible that the tattooed site may become infected, especially if I do not follow the instructions given to me. I agree that it is my responsibility to contact the practitioner or facility if there are signs or symptoms of infection including, but not limited to, significant swelling and tenderness of the procedure area, red streaks going from the procedure area towards the heart, elevated body temperature, or purulent drainage from the procedure area. If any touch-up work to the tattoo is needed due to my own negligence, I agree that the work will be done at my own expense.

I release all rights to any photographs taken of me and the procedure site and give consent in advance to their reproduction in print or electronic form:

YES
NO

I have eaten within the last 4 hours

YES
NO

I am not under the influence of alcohol or drugs, and I am voluntarily submitting to the application of a tattoo procedure by the practitioner without duress or coercion:

YES
NO

Check All That Apply:

Other Risk Factors for Bloodborne Pathogen Exposure:

Please list any other relevant medical details:

I am not the recipient of an organ or bone marrow transplant or, if I am, I have taken the prescribed preventive regimen of antibiotics that is required by my doctor in advance of any invasive procedure such as a tattoo procedure. I have not ingested anti-coagulants, anti-platelet or NSAIDS (aspirin, ibuprofen, etc.) which may inhibit the ability to heal my skin. I do not suffer from narcolepsy. I will consult a physician prior to the procedure if I have any concerns about any of these questions.

*** Tattoo inks and pigments have not been approved by the FDA and the health consequences of using these products are unknown ***

We follow all applicable regulations and standards as required by OSHA and local regulatory agencies.

The practitioner or the facility representative has given me the opportunity to ask any and all questions about the application of my tattoo procedure and all of my questions have been answered to my complete satisfaction.

I acknowledge that I have been given adequate opportunity to read and understand this document prior to receiving my procedure and that it was not presented to me at the last minute. I understand that I am signing a legal contract waiving certain rights to recover damages against the practitioner and the above said facility.

“Pursuant to Section 653 of the California Penal Code, a client shall be at least 18 years of age to be offered or to receive a tattoo regardless of parental consent.” I hereby declare that I am of legal age in this jurisdiction, have provided valid proof of age, I have complete understanding of this agreement, and I am competent to sign this Agreement.

I HAVE READ THIS AGREEMENT, I UNDERSTAND IT, AND I AGREE TO BE BOUND BY IT. ALL SALES FINAL.

Photo of Government Issued ID *

All information gathered from the client that is personal medical information and that is subject to the federal Health Insurance Portability and Accountability Act of 1996 (HIPPA) or similar state laws shall be maintained or disposed of in compliance with those provisions. If any provision, section, subsection, clause, or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.

Practitioner

Sterile Supplies, Instruments, Implements, and Inks Used

Team 444SVT RSS

Let's Book You a Session!