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Nightfall Tattoo Gallery

809 S Neil St

Champaign, IL 61820

Tattoo Release Form - October 27, 2021

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

Age *
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information

Age *
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information

Age *
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information

Age *
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information

Age *
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information

Age *
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information

Age *
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information

Age *
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information

Age *
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information

Age *
Client's 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*

Confirm Email*
Release of Liabilities
I request the artist at Nightfall to tattoo my body and in doing so, hereby release Nightfall and its employees and agents from all manner of liabilities, claims, actions, or demands, in law or in equity, which I or my heirs might now or hereafter, by complying with my request to be tattooed. *
I Agree
I understand that I will be tattooed using appropriate instruments and techniques. To insure proper healing of my tattoo, I agree to follow the aftercare guidelines that have been provided in the Aftercare pamphlet until healing is complete. I understand that this type of tattoo/procedure usually takes 2-3 weeks or longer to heal. I have made the decision to have this procedure done with the full understanding of possible complications such as, but not limited to, infection, allergic reaction or rejection of the tattoo. I understand that by having this tattoo performed, I am making a permanent change to my body and no claims have been made regarding the ability to undo any changes made. *
I Agree
Safety Information

To ensure that your body art procedure heals properly, we ask that you disclose if you have had any of the following conditions. Disclosure does not prevent you from having a body art procedure.

Have you eaten in the last 4 hours?*
No
Yes
Been diagnosed with Diabetes, Human immunodeficiency virus (HIV), or Hepatitis;*
No
Yes
Do you have any skin diseases, skin lesions or skin sensitivities to soaps, disinfectants, etc,;*
No
Yes
History of allergies or adverse reactions to pigments, dyes or other skin sensitivities such as, but not limited to latex, iodine, metals, etc;*
No
Yes
Are you prone to heavy bleeding, anemic or been diagnosed with hemophilia?*
No
Yes
Have a history of epilepsy, seizures, fainting or narcolepsy;*
No
Yes
Have you taken Aspirin, Ibuprophen or anticoagulants in the last 24 hours?*
No
Yes
Medications used, such as anticoagulants that thin the blood and/or interfere with blood clotting;*
No
Yes
Do you have Mitral Valve Prolapse or any other heart condition that requires antibiotics before dental work or other medical procedures?*
No
Yes
Are you pregnant or nursing?*
No
Yes
Have you consumed any drugs or alcohol in the last 24 hours?*
No
Yes

Do you have any other information that would aid in evaluating your body art healing process?
How did you hear about us?
Artist Information
Which artist will be tattooing you?*
Appointment Date

Date of your appointment *
Information Agreement
By Checking here, I certify under penalty of perjury that the above information is true and correct. I further understand that, if I give false information or produce false documents stating my name and age to be other than what is correct, that I am liable for prosecution. The Sterilization procedures used for my tattoo procedure were explained to my full satisfaction and that I had the opportunity to ask any questions regarding these procedures and/or my tattoo. All equipment used during the procedure was opened in front of me and I witnessed the disposal of the tattoo needle in the medical sharps container. Both verbal and written aftercare instructions were provided to me. I acknowledge the above comments by the tattoo artist regarding my procedure. *
I Agree
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.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Age *
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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