Name *

First Name

Last Name

Phone *

(###)

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Do you currently have or have had any of the following symptoms in the last 14 days? *

- severe cough - significant nasal congestion/runny nose - fever of 38 degrees celsius or higher - come into contact with anyone with these symptoms - failed to use social distancing or good hand hygiene - been in contact with anyone suspected or diagnosed with COVID-19 - returned from travel outside of province or country

Yes

No

*

I understand that I must honestly disclose this information to avoid putting myself and others at risk.

*

If I have diabetes, epilepsy, hepatitis, hemophilia, HIV-AIDS 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 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 acknowledge it is not reasonably possible for the representatives and employees of this tattoo shop 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 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. 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 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 and to any actions or conduct of the representatives and employees of the tattoo shop reasonably necessary to perform the tattoo procedure.

*

I fully understand THE TATTOO ARTIST 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.