Date *

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Name *

First Name

Last Name

Pronouns

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They/Them

He/Him

Other

Phone *

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Address

Address 1

Address 2

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Date of Birth *

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I acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions which I might have about the obtaining of a tattoo 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: *

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.

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, rash, infection, lesion, freckles, moles or sunburn in the area to be tattooed that may interfere with said tattoo. If I have any type of infection, rash, or lesion anywhere on my body, I will advise my tattooer..

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 or failure to follow such instructions, will be done at my own expense.

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 understand that Janelle Quibuyen reserves all rights to use any photos or videos of my tattoo. I may request that identifying features, such as my face, not be recorded or photographed.

I hereby release and forever discharge and hold harmless Janelle Quibuyen, the tattooer and all affiliates, Owners, Managers and Employees from any and all claims, damages or legal actions arising from or connected in any way with my tattoo, or the procedure and conduct used in my performing my tattoo, to the fullest extent allowed by the law.