Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact

First Name

Last Name

Emergency Contact Phone

(###)

###

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Media Release *

Can we post images of your completed tattoo on our website?

Yes

No

Are you under the influence of drugs or alcohol? *

Yes

No

Are you pregnant or nursing?

**Female Clients Only**

Yes

No

CURRENT HEALTH

Do you have any transmittable diseases, viruses or symptoms of illness? (It's okay if you do. We just need to know for our safety & the safety of others in the studio.)

Yes

No

I acknowledge and agree that... *

– The information I provided in this document is accurate and true. – I do not have a mental impairment that would affect my judgment. – This procedure constitutes a permanent change to my skin & body. – Variations may exist between the design and the actual tattoo, and over time, the colors and clarity of my tattoo will fade due to natural dispersion of pigment. – There is a risk of allergic reactions to tattoo pigment, latex gloves, and/or soap. The studio does not have a way of identifying if I am allergic to the elements or ingredients that will be used for my tattoo. – I must take care of my tattoo by following the instructions provided by the Artist. I know that there is a risk of infection if I do not properly care for my tattoo. – I have been fully informed of and understand all inherent risks, including but not limited to infection, scarring, difficulties in detecting melanoma. I freely accept and expressly assume any and all risks associated with the tattooing procedure. – Orchard Street Tattoos does not offer refunds. – I indemnify and hold harmless Orchard Street Tattoos against any claims, expenses, damages, and liabilities. – I acknowledge that I have been given adequate opportunity to read and understand this document and I understand that I am signing a legal contract waiving certain rights to recover against the Artist and the shop Orchard Street Tattoos. I AGREE TO WAIVE AND RELEASE TO THE FULLEST EXTENT PERMITTED BY LAW EACH OF THE ARTISTS AND 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 MY TATTOO, WHETHER CAUSED BY THE NEGLIGENCE OR FAULT OF EITHER THE ARTIST OR ORCHARD STREET TATTOOS, OR OTHERWISE.

I agree to the terms and conditions listed in this form.

Date *

MM

DD

YYYY