Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Phone Number *

(###)

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Are you taking any medications (prescribed or over the counter. This includes oral or topical skin medications)? *

Yes

No

Do you have any of the following conditions? *

This information is confidential and is only used to make sure your conditions will not complicate healing. Most of these conditions will not impact your ability to get tattooed, but will cause prolonged healing which will be discussed by your artist.

Asthma

Bleeding disorder

Cancer

Diabetes

HBV

HIV

Hep A / Hep B / Hep C

Pregnancy / Nursing

None

Other

Have you experienced any of the following symptoms in the last 72 hours? *

Cough

Fever

Shortness of Breath

Loss of Taste or Smell

Flu-Like Symptoms

None of the Above

Do you have any skin sensitivites? *

Yes

No

Terms & Conditions *

Please review each statement below and then sign at the bottom of this form indicating that you understand and agree to the terms of receiving this procedure from Jessie Barber, the practitioner at Pink Suede Tattoo, 6370 Sunset Blvd Suite 208, Los Angeles CA 20028. By signing below, I am agreeing to following: ✹ I am the person on the legal ID presented as proof that I am at least 18 years of age. ✹ I am not under the influence of alcohol or drugs and I am voluntarily submitting to be tattooed without duress or coercion. ✹ I understand there is a possibility of an allergic reaction and/or scarring. ✹ I agree to follow all instructions concerning the care of my body art and that any touch ups due to my negligence will be done at my own monetary expense. ✹ I agree to immediately notify the artist in the event that I feel lightheaded, dizzy or faint before, during or after the procedure. ✹ I understand that this procedure involves the deposition of permanent ink into my skin and if I choose to have it removed, it may be expensive and leave scars. ✹ I understand that tattoo inks, dyes and pigments have not been approved by the Federal Food and Drug Administration (FDA) and the health consequences of using these products are unknown. To my knowledge, I have no allergies to tattoo ink or cosmetic tattoo pigment. ✹ I understand that no guarantee has been made as to the results of this procedure and the final results may be different than they appeared on the day of my procedure. Pigments change and fade over time due to unique skin types, iron deficiency, sun exposure, etc. ✹ I have reviewed the FAQ on pinksuedetattoo.com prior to my appointment and understand the information and policies discussed there. ✹ I understand that there are no refunds for services rendered. ✹ I understand my responsibility to advise my artist of any concerns I have before they begin the procedure and believe I have sufficient information to give this informed consent. ✹ I understand that there is difficulty in detecting melanoma and Pink Suede Tattoo may not know how the procedure will or affect my skin. ✹ I have been informed on the risks of body art and cosmetic tattooing, including and not limited to infection, scarring, difficulties in detecting melanoma and allergic reactions to tattoo pigments and anesthetics. ✹ I understand the potential risks associated with this body art procedure and I assume any and all risk that may arise from this procedure. ✹ If I elect to use a topical anesthetic prior to or during my session, I certify that I am not allergic to Novocaine, Lidocaine, Tetracaine, Benzocaine, Triclosan or Epinephrine. I take full responsibility for any reaction resulting from the use of the topical anesthetics applied and waive and and all claims against Pink Suede Tattoo to the fullest extent permitted by law. ✹ I grant permission for my photos to be taken on today’s date. I understand that photographs taken of me during this session may be used, wholly or in part, on the internet, in any publication, portfolio, or display, or in any other print or electronic medium as this artist chooses, unless otherwise specified below. I will make no monetary or other claim against this artist for use of the photographs. I understand that my name may or may not be included/credited in any form of publication unless requested otherwise. I fully understand the questions, terms, and conditions of this Disclosure and Release Agreement. I accept to waive my rights for any claim against the technician for any reason whatsoever. I release Jessie Barber of all claims for injury, seen or unseen, that may occur as a result of this procedure. ✹ For brow clients only: I understand that cosmetic tattooing is designed will fade over time and should expect to schedule touch ups every 1-3 years to keep my cosmetic tattoo looking fresh. ✹ For brow clients only: I understand that my artist will use topical anesthetic both prior and during my session. For brow clients only: I have been given a chance to ask questions and make changes to my brow design drawing. By signing this form I am consenting and approving of the agrees brow design pre-draw.

I have read and agree to the above Terms and Services

This is how my artist may use my photos: *

The use of my images on social networks, publications, portfolios, and/or displays.

Please keep my photos private.

E-signature *

I certify that this form was completed by me and that all entries in it are true and complete to the best of my knowledge. I also certify that I have informed Pink Suede Tattoo of any additional conditions or factors that may impact my procedure. Please type your name below as your e-signature.

First Name

Last Name

Today's Date *

MM

DD

YYYY