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Informed Consent-COVID-19 Pandemic

I understand that I am opting for a service that is not urgent and not medically necessary.

I also understand that the coronavirus disease (COVID-19) has been declared a worldwide pandemic by the World Health Organization. I further understand COVID-19 is extremely contagious. State and federal health agencies recommend social distancing.

I hereby agree to indemnify and hold Iron Brush Tattoo harmless and release Iron Brush Tattoo from any liability whatsoever should I become infected with COVID-19 which may include but not be limited to claims for personal injury, loss of income, disability, illness and death.  Furthermore, I understand that this Agreement is subject to the laws of the State of Nebraska and further agree that the appropriate venue for any dispute involving this Agreement shall be Lancaster County, Nebraska.

I recognize that the staff at Iron Brush Tattoo are closely monitoring this situation and put in place reasonable preventive measures targeted to reduce the spread of this virus. However, given the nature of the virus, I understand there is an inherent risk of becoming infected with COVID-19 if I proceed with this elective service.

Accordingly I acknowledge and assume the risk of becoming infected with COVID-19, and any variation of mutation thereof, through this elective service and I gave my express permission for the staff at Iron Brush Tattoo to proceed with the same. This consent applies to any follow up of additional services in the upcoming months.

I understand that even if I have been tested for COVID-19 and received a negative test result, the tests may not have detected the virus or I may have contracted COVID-19 after the test. I will not hold that business and professional offering the service responsible for any liability related to COVID-19 and variation or mutation thereof.

I understand that exposure to COVID-19 before, during, or after my procedure(s) may result in complications and/or delayed healing.

I have been given the option to defer my service to a later date. However, I understand all the risks including those noted herein and I would like to proceed with this service. I have been offered a copy of this consent form.

I understand the explanation and consent to the procedure(s).

By signing below, I agree to notify my tattooer/piercer immediately if I experience any of the symptoms listed, or test positive for COVID19 in the next 14 days.

I understand that even with every reasonable measure taken, Iron Brush Tattoo, and its independent contractors, employees, staff and representatives cannot guarantee, with total certainty, that all risk of contracting an illness or virus such as Covid19, has been eliminated.

 

Dated: April 24, 2024 

First Clients Name

First Name*

Last Name*

Phone*
First Clients Age Acknowledgment*
First Clients Date of Birth*
I certify that I am 18 years of age or older
First Clients Information
Please check any of the following symptoms you have had in the last 3 weeks:
Cough or any other symptoms of COVID-19
Fever above normal temperature
Rash
Runny nose
Congestion
Loss of sense of taste or smell?
Shortness of breath or difficulty breathing
Chills or repeated shaking with chills
Muscle pain
Sore throat
Headache
No
Yes
Have you tested positive for COVID-19?*
No
Yes
Have you been notified that you have been exposed to COVID-19?*
No
Yes
Were you or a family member in close contact with a person known to have COVID-19?*
Yes
No
Are you living with anyone who is sick or quarantined or have symptoms of COVID-19?*
No
Yes
In the last month, have you traveled?*
No
Yes

If so, where?
Do you agree to social distancing and COVID-19 protocols while in the studio? Wearing a mask, and using good hand sanitation.*
Yes
No
First Clients Signature*
Second Clients Name

First Name*

Last Name*
Second Clients Date of Birth*
Second Clients Information
Please check any of the following symptoms you have had in the last 3 weeks:
Cough or any other symptoms of COVID-19
Fever above normal temperature
Rash
Runny nose
Congestion
Loss of sense of taste or smell?
Shortness of breath or difficulty breathing
Chills or repeated shaking with chills
Muscle pain
Sore throat
Headache
No
Yes
Have you tested positive for COVID-19?*
No
Yes
Have you been notified that you have been exposed to COVID-19?*
No
Yes
Were you or a family member in close contact with a person known to have COVID-19?*
Yes
No
Are you living with anyone who is sick or quarantined or have symptoms of COVID-19?*
No
Yes
In the last month, have you traveled?*
No
Yes

If so, where?
Do you agree to social distancing and COVID-19 protocols while in the studio? Wearing a mask, and using good hand sanitation.*
Yes
No
Third Clients Name

First Name*

Last Name*
Third Clients Date of Birth*
Third Clients Information
Please check any of the following symptoms you have had in the last 3 weeks:
Cough or any other symptoms of COVID-19
Fever above normal temperature
Rash
Runny nose
Congestion
Loss of sense of taste or smell?
Shortness of breath or difficulty breathing
Chills or repeated shaking with chills
Muscle pain
Sore throat
Headache
No
Yes
Have you tested positive for COVID-19?*
No
Yes
Have you been notified that you have been exposed to COVID-19?*
No
Yes
Were you or a family member in close contact with a person known to have COVID-19?*
Yes
No
Are you living with anyone who is sick or quarantined or have symptoms of COVID-19?*
No
Yes
In the last month, have you traveled?*
No
Yes

If so, where?
Do you agree to social distancing and COVID-19 protocols while in the studio? Wearing a mask, and using good hand sanitation.*
Yes
No
Fourth Clients Name

First Name*

Last Name*
Fourth Clients Date of Birth*
Fourth Clients Information
Please check any of the following symptoms you have had in the last 3 weeks:
Cough or any other symptoms of COVID-19
Fever above normal temperature
Rash
Runny nose
Congestion
Loss of sense of taste or smell?
Shortness of breath or difficulty breathing
Chills or repeated shaking with chills
Muscle pain
Sore throat
Headache
No
Yes
Have you tested positive for COVID-19?*
No
Yes
Have you been notified that you have been exposed to COVID-19?*
No
Yes
Were you or a family member in close contact with a person known to have COVID-19?*
Yes
No
Are you living with anyone who is sick or quarantined or have symptoms of COVID-19?*
No
Yes
In the last month, have you traveled?*
No
Yes

If so, where?
Do you agree to social distancing and COVID-19 protocols while in the studio? Wearing a mask, and using good hand sanitation.*
Yes
No
Fifth Clients Name

First Name*

Last Name*
Fifth Clients Date of Birth*
Fifth Clients Information
Please check any of the following symptoms you have had in the last 3 weeks:
Cough or any other symptoms of COVID-19
Fever above normal temperature
Rash
Runny nose
Congestion
Loss of sense of taste or smell?
Shortness of breath or difficulty breathing
Chills or repeated shaking with chills
Muscle pain
Sore throat
Headache
No
Yes
Have you tested positive for COVID-19?*
No
Yes
Have you been notified that you have been exposed to COVID-19?*
No
Yes
Were you or a family member in close contact with a person known to have COVID-19?*
Yes
No
Are you living with anyone who is sick or quarantined or have symptoms of COVID-19?*
No
Yes
In the last month, have you traveled?*
No
Yes

If so, where?
Do you agree to social distancing and COVID-19 protocols while in the studio? Wearing a mask, and using good hand sanitation.*
Yes
No
Sixth Clients Name

First Name*

Last Name*
Sixth Clients Date of Birth*
Sixth Clients Information
Please check any of the following symptoms you have had in the last 3 weeks:
Cough or any other symptoms of COVID-19
Fever above normal temperature
Rash
Runny nose
Congestion
Loss of sense of taste or smell?
Shortness of breath or difficulty breathing
Chills or repeated shaking with chills
Muscle pain
Sore throat
Headache
No
Yes
Have you tested positive for COVID-19?*
No
Yes
Have you been notified that you have been exposed to COVID-19?*
No
Yes
Were you or a family member in close contact with a person known to have COVID-19?*
Yes
No
Are you living with anyone who is sick or quarantined or have symptoms of COVID-19?*
No
Yes
In the last month, have you traveled?*
No
Yes

If so, where?
Do you agree to social distancing and COVID-19 protocols while in the studio? Wearing a mask, and using good hand sanitation.*
Yes
No
Seventh Clients Name

First Name*

Last Name*
Seventh Clients Date of Birth*
Seventh Clients Information
Please check any of the following symptoms you have had in the last 3 weeks:
Cough or any other symptoms of COVID-19
Fever above normal temperature
Rash
Runny nose
Congestion
Loss of sense of taste or smell?
Shortness of breath or difficulty breathing
Chills or repeated shaking with chills
Muscle pain
Sore throat
Headache
No
Yes
Have you tested positive for COVID-19?*
No
Yes
Have you been notified that you have been exposed to COVID-19?*
No
Yes
Were you or a family member in close contact with a person known to have COVID-19?*
Yes
No
Are you living with anyone who is sick or quarantined or have symptoms of COVID-19?*
No
Yes
In the last month, have you traveled?*
No
Yes

If so, where?
Do you agree to social distancing and COVID-19 protocols while in the studio? Wearing a mask, and using good hand sanitation.*
Yes
No
Eighth Clients Name

First Name*

Last Name*
Eighth Clients Date of Birth*
Eighth Clients Information
Please check any of the following symptoms you have had in the last 3 weeks:
Cough or any other symptoms of COVID-19
Fever above normal temperature
Rash
Runny nose
Congestion
Loss of sense of taste or smell?
Shortness of breath or difficulty breathing
Chills or repeated shaking with chills
Muscle pain
Sore throat
Headache
No
Yes
Have you tested positive for COVID-19?*
No
Yes
Have you been notified that you have been exposed to COVID-19?*
No
Yes
Were you or a family member in close contact with a person known to have COVID-19?*
Yes
No
Are you living with anyone who is sick or quarantined or have symptoms of COVID-19?*
No
Yes
In the last month, have you traveled?*
No
Yes

If so, where?
Do you agree to social distancing and COVID-19 protocols while in the studio? Wearing a mask, and using good hand sanitation.*
Yes
No
Ninth Clients Name

First Name*

Last Name*
Ninth Clients Date of Birth*
Ninth Clients Information
Please check any of the following symptoms you have had in the last 3 weeks:
Cough or any other symptoms of COVID-19
Fever above normal temperature
Rash
Runny nose
Congestion
Loss of sense of taste or smell?
Shortness of breath or difficulty breathing
Chills or repeated shaking with chills
Muscle pain
Sore throat
Headache
No
Yes
Have you tested positive for COVID-19?*
No
Yes
Have you been notified that you have been exposed to COVID-19?*
No
Yes
Were you or a family member in close contact with a person known to have COVID-19?*
Yes
No
Are you living with anyone who is sick or quarantined or have symptoms of COVID-19?*
No
Yes
In the last month, have you traveled?*
No
Yes

If so, where?
Do you agree to social distancing and COVID-19 protocols while in the studio? Wearing a mask, and using good hand sanitation.*
Yes
No
Tenth Clients Name

First Name*

Last Name*
Tenth Clients Date of Birth*
Tenth Clients Information
Please check any of the following symptoms you have had in the last 3 weeks:
Cough or any other symptoms of COVID-19
Fever above normal temperature
Rash
Runny nose
Congestion
Loss of sense of taste or smell?
Shortness of breath or difficulty breathing
Chills or repeated shaking with chills
Muscle pain
Sore throat
Headache
No
Yes
Have you tested positive for COVID-19?*
No
Yes
Have you been notified that you have been exposed to COVID-19?*
No
Yes
Were you or a family member in close contact with a person known to have COVID-19?*
Yes
No
Are you living with anyone who is sick or quarantined or have symptoms of COVID-19?*
No
Yes
In the last month, have you traveled?*
No
Yes

If so, where?
Do you agree to social distancing and COVID-19 protocols while in the studio? Wearing a mask, and using good hand sanitation.*
Yes
No
Parent or Guardian's Email Address

Email*

Confirm Email*
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*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
Please check any of the following symptoms you have had in the last 3 weeks:
Cough or any other symptoms of COVID-19
Fever above normal temperature
Rash
Runny nose
Congestion
Loss of sense of taste or smell?
Shortness of breath or difficulty breathing
Chills or repeated shaking with chills
Muscle pain
Sore throat
Headache
No
Yes
Have you tested positive for COVID-19?*
No
Yes
Have you been notified that you have been exposed to COVID-19?*
No
Yes
Were you or a family member in close contact with a person known to have COVID-19?*
Yes
No
Are you living with anyone who is sick or quarantined or have symptoms of COVID-19?*
No
Yes
In the last month, have you traveled?*
No
Yes

If so, where?
Do you agree to social distancing and COVID-19 protocols while in the studio? Wearing a mask, and using good hand sanitation.*
Yes
No
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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