CONSENT FORM

Consent to Receive Tattoo & Body Piercing Services

Your Name(Required)

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Birth Date(Required)

Age(Required)

Which services are you interested in?(Required)

Tattoo

Piercing

Service Date(Required)

Please tap the artist your appointment is with

Ray Ray (owner & artist)

Kortney Karat (owner, artist & piercer)

Tricia Chapman (artist)

Hank Moore (artist)

Mike Haack (artist)

Maizie Star (artist)

Alexander Wells (artist)

Cameryn Reese (junior artist)

Rachael Watt (piercing apprentice)

Health Questionnaire Checklist

PLEASE READ AND ANSWER QUESTIONS

Do you have a communicable disease?

Yes

No

FEMALE ONLY: Are you pregnant or nursing?

Yes

No

Do you have any skin conditions?

Yes

No

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General Health Conditions: (Select all that apply)

Heart Conditions

Diabetes

Epilepsy or history of seizures

Hemophilia or blood clotting disorders

Autoimmune disorder

Allergies to latex, pigments, or antibiotics

Infection & Healing Risks: (Select all that apply)

Prone to infections

Slow healing or past issues with wound healing

Allergic reactions to tattoo ink or permanent makeup

Compromised immune system

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Lifestyle & Substances: (Select all that apply)

Consumed alcohol or recreational drugs in the last 24 hours

Currently under the influence of any substance

Fainted or felt dizzy during previous body modifications

Medications & Treatments: (Select all that apply)

Currently taking blood thinners

Taking antibiotics or steroids

Receiving chemotherapy or radiation

Using topical creams in the tattoo area

Taking medications that may affect healing

Tattoo History & Other Considerations: (Select all that apply)

Previous tattoos

Problems with healing or allergic reactions to tattoos/piercings

Skin conditions, sunburn, or irritation in the tattoo area

Metal implants or pacemaker near the tattoo area

Acknowledgment and Waiver

PLEASE READ THE FOLLOWING AND SIGN AT THE BOTTOM

In consideration of receiving body art from the practitioner at Time Bomb Tattoo LLC (together with its employees and other technicians), I confirm the following by signing below:(Required)

I acknowledge by signing this AGREEMENT that I have been given the full opportunity to ask any questions I might have about my procedure 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: If I have diabetes, epilepsy, hemophilia, or any other communicable disease, heart condition or take medicine which thins the blood I have advised my tattooer. I am not pregnant or nursing. 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. I acknowledge it is not reasonably possible for Time Bomb Tattoo LLC (together with its employees and other technicians) 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 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 my Tattoo may vary slightly from the design I have chosen. I understand it is not guaranteed to be exact. I understand that if my tattoo is on my hand(s) or feet, due to the nature of healing in these areas, touchups needed will be done at my own expense. I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my tattoo. I 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. I understand that a Tattoo is considered permanent and may only be removed with a surgical procedure. I understand that any effective removal of a Tattoo or body piercing may leave scarring. 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 am not under the influence of alcohol or drugs, and I am voluntarily submitting myself to receive body art without duress or coercion. I understand that there is a chance I might feel lightheaded or dizzy during or after receiving body art. I agree to immediately notify my artist in the event I feel lightheaded, dizzy, and/or faint before, during or after the procedure. I am the person on the legal ID presented as proof that I am at least 18 years of age. I am the parent or legal guardian of the client. (Only applies to underage) I acknowledge I am over the age of eighteen and that I have truthfully represented to my tattooer that the obtaining of a tattoo is by my choice alone. I consent to the application of the tattoo/body piercing and to any actions or conduct of Time Bomb Tattoo LLC (together with its employees and other technicians) as reasonably necessary to perform the tattoo procedure. I acknowledge the information I provided in the medical questionnaire is complete and true to the best of my knowledge. I understand the restrictions associated with this body art procedure as explained by the technician. I understand that any medical information obtained will be subject to the federal Health Insurance Portability and Accountability Act of 1996 (HIPPA) I understand there is a possibility of getting an infection as a result of receiving body art, 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 am aware of the signs and symptoms of infection, including but not limited to, redness, swelling, tenderness of the procedure site, red streaks going from the procedure site toward the heart, elevated body temperature, or purulent draining from the procedure site. I will seek professional medical attention if signs and symptoms of infection occur. All questions about the body art procedure have been answered to my satisfaction, and I have been given written aftercare instructions. I fully understand Time Bomb Tattoo LLC (together with its employees and other technicians) DOES NOT ACT AS A MEDICAL PROFESSIONAL. Any suggestions made to me are NOT to be construed as or substituted for advice from a medical professional.

Signature(Required)

Signed Date(Required)

Upload a clear image of your Operator ID, State ID, or Passport. If a minor, upload birth certificate and Parent/Legal Guardians ID.(Required)

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Max. file size: 32 MB, Max. files: 5.

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CONSENT FORM

CONSENT FORM

Consent to Receive Tattoo & Body Piercing Services

Health Questionnaire Checklist

Acknowledgment and Waiver

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