(reprinted by permission -- highlighting added) *************** TATTOO SANTA BARBARA 318 STATE ST, SANTA BARBARA, CA 93101 USA (805) 962-7552 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
INITIAL CONSENT TO APPLICATION OF TATTOO BOXES RELEASE AND WAIVER OF ALL CLAIMS *****************************************************************************
( ) I acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions I might have about the obtaining of a tattoo from the staff of Tattoo Santa Barbara and that all of my questions have been answered to my full and total satisfaction. I specifically acknowledge by initialing that I have read this document and have been advised of the facts set forth below, and I agree as follows: ( ) I do not have diabetes, epilepsy, hepatitis, hemophilia, HIV-AIDS, tuberculosis or any other communicable disease, a heart condition, or take medicine which thins the blood. 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. I am not a lawyer, nor do I work for one. ( ) I acknowledge that it is not reasonably possible for the representatives or owner of Tattoo Santa Barbara 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, and I agree to follow all instructions concerning the care of my own tattoo while it is healing. I have been given these instructions, understand and will follow them. 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. If my tattoo is a symbol, or something written in a language other than English, the tattoo artists and the owner of this business are not responsible for what it may or may not mean. ( ) 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. To my knowledge, I don’t 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 any tattoo-related work done at this time. ( ) I acknowledge that I have truthfully represented with photo ID to the representatives of Tattoo Santa Barbara that I am eighteen years of age or older, and that this information is true and correct. ( ) 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 owner or contractors of Tattoo Santa Barbara reasonably necessary to perform the tattoo proceedure. I release all rights to any photographs taken, and give my complete advance consent for their reproduction in any print or electronic form, or exibition in any venue. ( ) I agree to release and hold harmless Tattoo Santa Barbara, its owner and contractors from any and all claims, damages, or legal actions arising from or connected in any way with my tattoo or the proceedures and conduct used to apply my tattoo. ********************************** PLEASE PRINT: *********************************** Name:_________________________________________Phone: (_____)_________________ Address:________________________________City & State___________________________ Birth Date:_____________Age today:______ Signature:______________________________ Tattoo Design:________________________________________________________________ Payment :________________ Date Tattoo Completed:___________________ Artist: ( ) Pat Fish ( )
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