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CONSENT WAIVER FOR TATTOOS ONLY

Don't forget to bring government issued photo ID with you to your appointment, its required!

 


CLIENT HEALTH QUESTIONNAIRE 

PRIOR TO THE START OF MY SERVICE, I CONFIRM THAT: 

 

Disclosure Statement

● As with any invasive procedure, tattooing may involve possible health risks. These risks may include: pain, bleeding, swelling, infection, scarring of the area, and nerve damage. The following conditions may increase health risks associated with receiving a tattoo- 

  1. history of diabetes;
  2. history of hemophilia (bleeding);
  3. history of skin diseases, skin lesions, or skin sensitivities to soaps, Disinfectants etc.;
  4.  history of allergies or adverse reactions to pigments, dyes, or other sensitivities;
  5. history of epilepsy, seizures, fainting, or narcolepsy;
  6. use of medications such as anticoagulants, which thin the blood and/or interfere with blood clotting; and
  7.  any other Conditions such as hepatitis or HIV.

 ● Unsterile equipment and needles can spread infectious diseases; it is extremely important to be sure that all equipment is clean and sanitary before use. 

● The Body Art practitioner should properly and thoroughly cleanse the area before the procedure, use sterile equipment, use sterile techniques, and provide information on the aftercare of the area receiving body art. 

● You may not be allowed to donate blood either temporarily or permanently.

This disclosure statement is as per the Northampton Board of Health and the Easthampton Board of Health 210 Main St. Room 8, Northampton MA 01060 (413) 587-1214 and 50 Payton Ave MA 01027 (413) 529-1400 ext. 430


Date: October 10, 2024





First Client's Name

First Name*

Last Name*

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

Pronouns:

Preferred name:

Age *

Tattoo artist name

Area being tattooed

 I hereby release Lucky's and its employees and agents from all manner of liabilities, claims, actions and demands, in law and equity, which I or my heirs have or might have now or hereafter by reason of complying with my request to be tattooed, I fully understand that any employee or agent of Lucky's, when performing body modifications does not act in the capacity of a medical professional. Suggestions made by an employee or agent of Lucky's are not to be construed as, or substituted for, advice from a medical professional.

Accept

I understand that this type of modification usually takes 4-6 weeks or longer to heal. I willingly submit to these procedures with full understanding of possible complications such as, but not limited to; infection, allergic reaction, or bodily rejection of the tattoo. 

Accept
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. (If you do not accept this provision, please advise and remind the tattoo artist NOT to take any pictures of you)*
First Client's Signature*
Second Client's Name

First Name*

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

Pronouns:

Preferred name:

Age *

Tattoo artist name

Area being tattooed

 I hereby release Lucky's and its employees and agents from all manner of liabilities, claims, actions and demands, in law and equity, which I or my heirs have or might have now or hereafter by reason of complying with my request to be tattooed, I fully understand that any employee or agent of Lucky's, when performing body modifications does not act in the capacity of a medical professional. Suggestions made by an employee or agent of Lucky's are not to be construed as, or substituted for, advice from a medical professional.

Accept

I understand that this type of modification usually takes 4-6 weeks or longer to heal. I willingly submit to these procedures with full understanding of possible complications such as, but not limited to; infection, allergic reaction, or bodily rejection of the tattoo. 

Accept
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. (If you do not accept this provision, please advise and remind the tattoo artist NOT to take any pictures of you)*
Third Client's Name

First Name*

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

Pronouns:

Preferred name:

Age *

Tattoo artist name

Area being tattooed

 I hereby release Lucky's and its employees and agents from all manner of liabilities, claims, actions and demands, in law and equity, which I or my heirs have or might have now or hereafter by reason of complying with my request to be tattooed, I fully understand that any employee or agent of Lucky's, when performing body modifications does not act in the capacity of a medical professional. Suggestions made by an employee or agent of Lucky's are not to be construed as, or substituted for, advice from a medical professional.

Accept

I understand that this type of modification usually takes 4-6 weeks or longer to heal. I willingly submit to these procedures with full understanding of possible complications such as, but not limited to; infection, allergic reaction, or bodily rejection of the tattoo. 

Accept
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. (If you do not accept this provision, please advise and remind the tattoo artist NOT to take any pictures of you)*
Fourth Client's Name

First Name*

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

Pronouns:

Preferred name:

Age *

Tattoo artist name

Area being tattooed

 I hereby release Lucky's and its employees and agents from all manner of liabilities, claims, actions and demands, in law and equity, which I or my heirs have or might have now or hereafter by reason of complying with my request to be tattooed, I fully understand that any employee or agent of Lucky's, when performing body modifications does not act in the capacity of a medical professional. Suggestions made by an employee or agent of Lucky's are not to be construed as, or substituted for, advice from a medical professional.

Accept

I understand that this type of modification usually takes 4-6 weeks or longer to heal. I willingly submit to these procedures with full understanding of possible complications such as, but not limited to; infection, allergic reaction, or bodily rejection of the tattoo. 

Accept
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. (If you do not accept this provision, please advise and remind the tattoo artist NOT to take any pictures of you)*
Fifth Client's Name

First Name*

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

Pronouns:

Preferred name:

Age *

Tattoo artist name

Area being tattooed

 I hereby release Lucky's and its employees and agents from all manner of liabilities, claims, actions and demands, in law and equity, which I or my heirs have or might have now or hereafter by reason of complying with my request to be tattooed, I fully understand that any employee or agent of Lucky's, when performing body modifications does not act in the capacity of a medical professional. Suggestions made by an employee or agent of Lucky's are not to be construed as, or substituted for, advice from a medical professional.

Accept

I understand that this type of modification usually takes 4-6 weeks or longer to heal. I willingly submit to these procedures with full understanding of possible complications such as, but not limited to; infection, allergic reaction, or bodily rejection of the tattoo. 

Accept
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. (If you do not accept this provision, please advise and remind the tattoo artist NOT to take any pictures of you)*
Sixth Client's Name

First Name*

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

Pronouns:

Preferred name:

Age *

Tattoo artist name

Area being tattooed

 I hereby release Lucky's and its employees and agents from all manner of liabilities, claims, actions and demands, in law and equity, which I or my heirs have or might have now or hereafter by reason of complying with my request to be tattooed, I fully understand that any employee or agent of Lucky's, when performing body modifications does not act in the capacity of a medical professional. Suggestions made by an employee or agent of Lucky's are not to be construed as, or substituted for, advice from a medical professional.

Accept

I understand that this type of modification usually takes 4-6 weeks or longer to heal. I willingly submit to these procedures with full understanding of possible complications such as, but not limited to; infection, allergic reaction, or bodily rejection of the tattoo. 

Accept
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. (If you do not accept this provision, please advise and remind the tattoo artist NOT to take any pictures of you)*
Seventh Client's Name

First Name*

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

Pronouns:

Preferred name:

Age *

Tattoo artist name

Area being tattooed

 I hereby release Lucky's and its employees and agents from all manner of liabilities, claims, actions and demands, in law and equity, which I or my heirs have or might have now or hereafter by reason of complying with my request to be tattooed, I fully understand that any employee or agent of Lucky's, when performing body modifications does not act in the capacity of a medical professional. Suggestions made by an employee or agent of Lucky's are not to be construed as, or substituted for, advice from a medical professional.

Accept

I understand that this type of modification usually takes 4-6 weeks or longer to heal. I willingly submit to these procedures with full understanding of possible complications such as, but not limited to; infection, allergic reaction, or bodily rejection of the tattoo. 

Accept
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. (If you do not accept this provision, please advise and remind the tattoo artist NOT to take any pictures of you)*
Eighth Client's Name

First Name*

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

Pronouns:

Preferred name:

Age *

Tattoo artist name

Area being tattooed

 I hereby release Lucky's and its employees and agents from all manner of liabilities, claims, actions and demands, in law and equity, which I or my heirs have or might have now or hereafter by reason of complying with my request to be tattooed, I fully understand that any employee or agent of Lucky's, when performing body modifications does not act in the capacity of a medical professional. Suggestions made by an employee or agent of Lucky's are not to be construed as, or substituted for, advice from a medical professional.

Accept

I understand that this type of modification usually takes 4-6 weeks or longer to heal. I willingly submit to these procedures with full understanding of possible complications such as, but not limited to; infection, allergic reaction, or bodily rejection of the tattoo. 

Accept
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. (If you do not accept this provision, please advise and remind the tattoo artist NOT to take any pictures of you)*
Ninth Client's Name

First Name*

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

Pronouns:

Preferred name:

Age *

Tattoo artist name

Area being tattooed

 I hereby release Lucky's and its employees and agents from all manner of liabilities, claims, actions and demands, in law and equity, which I or my heirs have or might have now or hereafter by reason of complying with my request to be tattooed, I fully understand that any employee or agent of Lucky's, when performing body modifications does not act in the capacity of a medical professional. Suggestions made by an employee or agent of Lucky's are not to be construed as, or substituted for, advice from a medical professional.

Accept

I understand that this type of modification usually takes 4-6 weeks or longer to heal. I willingly submit to these procedures with full understanding of possible complications such as, but not limited to; infection, allergic reaction, or bodily rejection of the tattoo. 

Accept
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. (If you do not accept this provision, please advise and remind the tattoo artist NOT to take any pictures of you)*
Tenth Client's Name

First Name*

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

Pronouns:

Preferred name:

Age *

Tattoo artist name

Area being tattooed

 I hereby release Lucky's and its employees and agents from all manner of liabilities, claims, actions and demands, in law and equity, which I or my heirs have or might have now or hereafter by reason of complying with my request to be tattooed, I fully understand that any employee or agent of Lucky's, when performing body modifications does not act in the capacity of a medical professional. Suggestions made by an employee or agent of Lucky's are not to be construed as, or substituted for, advice from a medical professional.

Accept

I understand that this type of modification usually takes 4-6 weeks or longer to heal. I willingly submit to these procedures with full understanding of possible complications such as, but not limited to; infection, allergic reaction, or bodily rejection of the tattoo. 

Accept
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. (If you do not accept this provision, please advise and remind the tattoo artist NOT to take any pictures of you)*
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*
Check to be added to Lucky’s mailing list to receive exclusive promotional information and updates. (we will never rent, sell, or share your information!)
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 Date of Birth*
Parent or Guardian's Information

Pronouns:

Preferred name:

Age *

Tattoo artist name

Area being tattooed

 I hereby release Lucky's and its employees and agents from all manner of liabilities, claims, actions and demands, in law and equity, which I or my heirs have or might have now or hereafter by reason of complying with my request to be tattooed, I fully understand that any employee or agent of Lucky's, when performing body modifications does not act in the capacity of a medical professional. Suggestions made by an employee or agent of Lucky's are not to be construed as, or substituted for, advice from a medical professional.

Accept

I understand that this type of modification usually takes 4-6 weeks or longer to heal. I willingly submit to these procedures with full understanding of possible complications such as, but not limited to; infection, allergic reaction, or bodily rejection of the tattoo. 

Accept
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. (If you do not accept this provision, please advise and remind the tattoo artist NOT to take any pictures of 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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