waiver

Name *

First Name

Last Name

Date of Birth *

You must be 18 years of age or older to be tattooed.

MM

DD

YYYY

You are 18 years of age or older *

Yes

Phone *

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Adress *

(###)

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If I am feeling any respiratory issues, have a fever, or flu/common cold symptoms I will not come into the studio and will give as much notice as possible to reschedule my appointment.

Yes

I have been fully informed of the inherent risks, associated with getting a tattoo. I fully understand that these risks, known and unknown, can compromise the immune system, lead to injury, including but not limited to infection, scarring, difficulties in detecting melanoma and allergic reactions to tattoo pigment, latex gloves, and/or soap. Having been informed of the potential risks associated with getting a tattoo, I still wish to proceed with the tattoo application and I freely accept and expressly assume any and all risks that may arise from tattooing. * *

Yes

No

I waive and release to the fullest extent permitted by law the Artist Mika Ferguson 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 the application of my tattoo, whether caused by the negligence or fault of the Artist Mika Ferguson, or otherwise *

Yes

The Artsit Mika Ferguson has given me the full opportunity to ask any and all questions about the application of my tattoo and all of my questions have been answered to my complete satisfaction. *

Yes

The Artist Mika Ferguson has given me instructions on the care of my tattoo while it’s healing, and I understand them and will follow them. I acknowledge that it is possible that the tattoo can become infected, particularly if I do not follow the instructions given to me. *

Yes

I understand that touch ups can range from $20.00 to the full rate, especially if I do not take care of my tattoo or follow the Artist’s after care instructions. This rate is entirely subject to the tattooist’s discretion. *

Yes

During my tattoo session, I will not be under the influence of alcohol or drugs, and I am voluntarily submitting to be tattooed by the Artist Mika Ferguson without duress or coercion. *

Correct

I understand that the Artist is not responsible for the meaning or spelling of the symbol or text that I have chosen to get tattooed. *

Yes

I am aware that variations in color and design may exist between the tattoo art I have selected and the actual tattoo when it is applied to my body. I also understand that over time, the colors and the clarity of my tattoo will fade due to unprotected exposure to the sun and the naturally occurring dispersion of pigment under the skin. *

Yes

I understand that a tattoo is a permanent change to my appearance and can only be removed by laser or surgical means, which can be disfiguring and/or costly and which in all likelihood will not result in the restoration of my skin to its exact appearance before being tattooed. *

Yes

Please check any of the following conditions that apply to you and/or elaborate further below *

Severe difficulty breathing (e.g. struggling to breathe or speaking in single words)

Severe difficulty breathing (e.g. struggling to breathe or speaking in single words)

Severe chest pain

Seizures

Blood Disorders

Diabetes

Epilepsy

Hemophilia

Tested Positive for HIV

Hepatitis

Prone to fainting

Other*

NONE

I do not have any other medical or skin conditions that I have not listed above that may interfere with the application or healing of the tattoo. I am not pregnant or nursing. I do not have a mental impairment that may affect my judgment in getting the tattoo. *

Yes

Other

I am NOT currently breastfeeding or pregnant. *

Yes

I release all rights to any photographs taken of me and the tattoo and give consent in advance to their reproduction in print or electronic form. Please note: If you do not initial this provision, please advise and remind your Artist not to take any pictures of you and your completed tattoo. *

Yes

No

If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document. I hereby declare that I am of legal age (and have provided or will provide valid proof of age on the day of my tattoo) and am competent to sign this Agreement. *

Yes

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 Mika Ferguson. *

Yes