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CONSENT OF APPLICATION OF TATTOO and RELEASE AND WAIVER OF ALL CLAIMS

PLEASE CHECK ALL THAT APPLY:

I acknowledge that I have truthfully represented to the associates, agents, and representatives of Black Rabbit Tattoo that I am at least eighteen (18) years of age.

I Agree

I acknowledge that tattooing is an invasive procedure in which the skin is penetrated by a foreign object. 

I Agree

I acknowledge that if proper sterilization and antiseptic procedures are not followed by tattoo artists there is a risk of transmission of blood-borne pathogens and other infections, including, but not limited to, human immunodeficiency viruses (HIV) and hepatitis B or C viruses. 

I Agree

I acknowledge that tattooing may cause allergic reactions in persons sensitive to dyes. 

I Agree

I acknowledge that tattooing involves discomfort or pain in which appropriate anesthesia cannot be legally made available by the person performing the tattoo, unless such person holds the appropriate license from a Virginia health regulatory board. 

I Agree

I acknowledge that I am not pregnant. 

I Agree

I acknowledge that I am free of communicable disease. 

I Agree

I acknowledge that tattooing may increase sensitivity to keloid formation. 

I Agree

I acknowledge that I have read the aftercare instructions provided by the shop or artist. These can be found in the FAQ section of our web site.

I Agree

I acknowledge that variations of color and design may exist between any tattoos, as selected by me, and as ultimately applied to my body. 

I Agree

I acknowledge that tattooing is a permanent change to my appearance and that no representations have been made to me as to the ability to later change, alter or remove my tattooo. 

I Agree

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 associates, agents or representatives of Black Rabbit Tattoo reasonably necessary to perform the tattoo procedure. 

I Agree

I agree to release and forever discharge and hold harmless Black Rabbit Tattoo and its associates, agents, officers, and shareholders from any and all claims, damages, or legal actions arising from, or connected in any way with, my tattoo or the procedures and conduct used to apply my tattoo. 

I Agree

By signing below I acknowledge that I have read the above information and that I have been given the full opportunity to ask any and all questions I might have about obtaining a tattoo from Black Rabbit Tattoo. I acknowledge that all of my questions have been answered to my full and total satisfaction.

Date: May 15, 2025

*ATTENTION* Please enter your PREFERRED name below. You'll be asked for your legal name later!
First Client Name
First Name*
Last Name*
Phone*
First Client Date of Birth*
Date of Birth
First Client Information
Client's Age *
Type of ID Provided *
Pronouns
Please List Any Known Allergies:
Any Accessibility Concerns? (weight capacities, wheelchair access, injuries, etc.)
Do you acknowledge that security cameras are recording at all times?*
Yes
No
Short Description of Tattoo
Tattoo Location on the Body
First Client Signature*
Second Client Name
First Name*
Last Name*
Client Date of Birth*
Date of Birth
Second Client Information
Client's Age *
Type of ID Provided *
Pronouns
Please List Any Known Allergies:
Any Accessibility Concerns? (weight capacities, wheelchair access, injuries, etc.)
Do you acknowledge that security cameras are recording at all times?*
Yes
No
Short Description of Tattoo
Tattoo Location on the Body
Third Client Name
First Name*
Last Name*
Client Date of Birth*
Date of Birth
Third Client Information
Client's Age *
Type of ID Provided *
Pronouns
Please List Any Known Allergies:
Any Accessibility Concerns? (weight capacities, wheelchair access, injuries, etc.)
Do you acknowledge that security cameras are recording at all times?*
Yes
No
Short Description of Tattoo
Tattoo Location on the Body
Fourth Client Name
First Name*
Last Name*
Client Date of Birth*
Date of Birth
Fourth Client Information
Client's Age *
Type of ID Provided *
Pronouns
Please List Any Known Allergies:
Any Accessibility Concerns? (weight capacities, wheelchair access, injuries, etc.)
Do you acknowledge that security cameras are recording at all times?*
Yes
No
Short Description of Tattoo
Tattoo Location on the Body
Fifth Client Name
First Name*
Last Name*
Client Date of Birth*
Date of Birth
Fifth Client Information
Client's Age *
Type of ID Provided *
Pronouns
Please List Any Known Allergies:
Any Accessibility Concerns? (weight capacities, wheelchair access, injuries, etc.)
Do you acknowledge that security cameras are recording at all times?*
Yes
No
Short Description of Tattoo
Tattoo Location on the Body
Sixth Client Name
First Name*
Last Name*
Client Date of Birth*
Date of Birth
Sixth Client Information
Client's Age *
Type of ID Provided *
Pronouns
Please List Any Known Allergies:
Any Accessibility Concerns? (weight capacities, wheelchair access, injuries, etc.)
Do you acknowledge that security cameras are recording at all times?*
Yes
No
Short Description of Tattoo
Tattoo Location on the Body
Seventh Client Name
First Name*
Last Name*
Client Date of Birth*
Date of Birth
Seventh Client Information
Client's Age *
Type of ID Provided *
Pronouns
Please List Any Known Allergies:
Any Accessibility Concerns? (weight capacities, wheelchair access, injuries, etc.)
Do you acknowledge that security cameras are recording at all times?*
Yes
No
Short Description of Tattoo
Tattoo Location on the Body
Eighth Client Name
First Name*
Last Name*
Client Date of Birth*
Date of Birth
Eighth Client Information
Client's Age *
Type of ID Provided *
Pronouns
Please List Any Known Allergies:
Any Accessibility Concerns? (weight capacities, wheelchair access, injuries, etc.)
Do you acknowledge that security cameras are recording at all times?*
Yes
No
Short Description of Tattoo
Tattoo Location on the Body
Ninth Client Name
First Name*
Last Name*
Client Date of Birth*
Date of Birth
Ninth Client Information
Client's Age *
Type of ID Provided *
Pronouns
Please List Any Known Allergies:
Any Accessibility Concerns? (weight capacities, wheelchair access, injuries, etc.)
Do you acknowledge that security cameras are recording at all times?*
Yes
No
Short Description of Tattoo
Tattoo Location on the Body
Tenth Client Name
First Name*
Last Name*
Client Date of Birth*
Date of Birth
Tenth Client Information
Client's Age *
Type of ID Provided *
Pronouns
Please List Any Known Allergies:
Any Accessibility Concerns? (weight capacities, wheelchair access, injuries, etc.)
Do you acknowledge that security cameras are recording at all times?*
Yes
No
Short Description of Tattoo
Tattoo Location on the Body
Legal Name
Enter your legal name *
Please upload a photo of your ID (front only)
Click to customize text box label *
  
Valid file types: JPG, GIF, PNG, and PDF
Client Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address
Email
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Client Date of Birth*
Date of Birth
Parent or Guardian's Information
Client's Age *
Type of ID Provided *
Pronouns
Please List Any Known Allergies:
Any Accessibility Concerns? (weight capacities, wheelchair access, injuries, etc.)
Do you acknowledge that security cameras are recording at all times?*
Yes
No
Short Description of Tattoo
Tattoo Location on the Body
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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