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Welcome to the Industrial Tattoo & Piercing

Online Tattoo Release Form!

Please read the following thoroughly. After completing the waiver, you will be required to provide any and all forms of Valid ID to the Industrial Counter Staff up arrival, prior to being tattooed! For examples of Valid Identification, please visit our website www.IndustrialTattooAndPiercing.com

First Client Name

First Name*

Middle Name

Last Name*

Phone*
First Client Date of Birth*
First Client Tattoo Artist
Which artist will be tattooing you?*
First Client Signature*
Second Client Name

First Name*

Middle Name

Last Name*
Second Client Date of Birth*
Second Client Tattoo Artist
Which artist will be tattooing you?*
Third Client Name

First Name*

Middle Name

Last Name*
Third Client Date of Birth*
Third Client Tattoo Artist
Which artist will be tattooing you?*
Fourth Client Name

First Name*

Middle Name

Last Name*
Fourth Client Date of Birth*
Fourth Client Tattoo Artist
Which artist will be tattooing you?*
Fifth Client Name

First Name*

Middle Name

Last Name*
Fifth Client Date of Birth*
Fifth Client Tattoo Artist
Which artist will be tattooing you?*
Sixth Client Name

First Name*

Middle Name

Last Name*
Sixth Client Date of Birth*
Sixth Client Tattoo Artist
Which artist will be tattooing you?*
Seventh Client Name

First Name*

Middle Name

Last Name*
Seventh Client Date of Birth*
Seventh Client Tattoo Artist
Which artist will be tattooing you?*
Eighth Client Name

First Name*

Middle Name

Last Name*
Eighth Client Date of Birth*
Eighth Client Tattoo Artist
Which artist will be tattooing you?*
Ninth Client Name

First Name*

Middle Name

Last Name*
Ninth Client Date of Birth*
Ninth Client Tattoo Artist
Which artist will be tattooing you?*
Tenth Client Name

First Name*

Middle Name

Last Name*
Tenth Client Date of Birth*
Tenth Client Tattoo Artist
Which artist will be tattooing you?*
Parent or Guardian's Email Address

Email*

Confirm Email*
Blood Born Pathogens
Do you have any blood born pathogens, transmittable diseases or recent illnesses? (It's okay if you do, we just want to know for everyone's safety)*
No
Yes
Risks
By checking yes, I understand that I will be fully informed of the inherent risks associated with getting a tattoo prior to being tattooed and understand that I may ask any questions regarding risks at any time throughout the process. I fully understand that these risks, known and unknown, can 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, I still wish to proceed with the tattoo application and I freely accept and expressly assume any and all risks.*
No
Yes
Waive
By checking 'Yes', I choose to waive and release to the fullest extent permitted by law, each the artist and the studio 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 my tattoo, whether caused by the negligence or fault of either the artist or the tattoo studio.*
No
Yes
Healing
By Checking 'Yes', I understand that I will be given proper instructions on the aftercare 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. If any touch-upwork to the tattoo is needed due to my own negligence, I agree that the work will be done at my own expense.*
No
Yes
Influence
By checking 'Yes', I agree that I will not be under the influence of alcohol or drugs at the time of receiving the tattoo, and that I am voluntarily submitting to be tattooed by the artist without duress or coercion.*
No
Yes
Health
By checking 'Yes', I agree that I DO NOT have diabetes, epilepsy, hemophilia, a heart condition, nor do I take blood thinning medication. I do not have any other condition that may interfere with the application or healing of the tattoo. I am not the recipient of an organ or bone marrow transplant or, if I am, I have taken the preventative antibiotics. I am not pregnant or nursing. I do not have a mental impairment that may affect my judgement in getting the tattoo.*
No
Yes
Spelling
By checking 'Yes', I understand that neither the artist nor the studio is responsible for the meaning or spelling of the symbol or text that I have provided to them or chosen from any flash/design sheets.*
No
Yes
Fading
By checking 'Yes', I understand that variations in the color and design may exists between the art I have selected and the actual tattoo. I also understand that over time, the colors and the clarity of my tattoo will fade due to natural dispersion of pigment under the skin.*
No
Yes
Permanence
By checking '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.*
No
Yes
Questions
By checking 'Yes', I acknowledge that I have been given adequate opportunity to read and understand this document, that any and all of my questions may be answered, and that this document was not presented to me at the last minute. I also understand that I am signing a legal contract waiving certain rights to recover against the artist and the studio.*
No
Yes
Photography
By checking 'Yes', I agree to 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. If you do not agree, do NOT check 'Yes' and please advise your artist.*
No
Yes
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*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Tattoo Artist
Which artist will be tattooing you?*
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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