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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!

 

Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19 

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people 

Lucky’s Tattoo and Piercing have put in place preventative measures to reduce the spread of COVID-19; however, Lucky’s Tattoo and Piercing cannot guarantee that you will not become infected with COVID-19. Further, getting a tattoo or piercing could increase your risk of contracting COVID-19. 

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By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by entering Lucky’s Tattoo and Piercing and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Lucky’s Tattoo and Piercing employees. 

I voluntarily agree to assume all of the possible risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury. disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my attendance at Lucky’s Tattoo and Piercing.

 

I hereby release, discharge, and hold harmless Lucky’s Tattoo and Piercing LLC, its employees, agents, of and from the Claims, including all liabilities, claims, actions, damages, costs, or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of Lucky’s Tattoo and Piercing employees, agents, whether a COVID-19 infection occurs before, during, or after participation in any tattoo, piercing work, or any other services provided by Lucky’s Tattoo and Piercing LLC.

 

I Agree


 

CLIENT HEALTH QUESTIONNAIRE 

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

 

I have not been diagnosed with or cared for someone diagnosed with COVID-19 in the past two weeks.

I Agree

I have not shown symptoms of COVID-19 or come in close contact with anyone exhibiting these symptoms in the past two weeks. 

I Agree

I have not traveled outside of my immediate daily routine for the past two weeks. 

I Agree

I do not have a cough, fever, chills, shortness of breath, or loss of taste or smell. 

I Agree

If I begin to show symptoms of COVID-19 within the next two weeks, I will contact Lucky's Tattoo and Piercing as soon as possible.

I Agree

I will follow all posted studio rules to keep myself, studio staff, and those around me safe. 

I Agree

 

 

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I understand I will be tattooed using appropriate instruments and techniques, and I acknowledge that infection is always possible as a result of obtaining a tattoo. To ensure proper healing of my tattoo, I agree to follow the directions given to me following my tattoo procedure.  

I Agree

 

Health History and Informed Consent

The following conditions may increase health risks associated with receiving body art:

  1. I am not pregnant or nursing. I do not have epilepsy, diabetes or hemophilia. I do not suffer from any heart conditions or take medications that thin the blood. I am not under the influence of drugs or alcohol.
    I Agree
  2. If I suffer from hepatitis, HIV or other communicable disease, I have the opportunity to inform the tattoo artist of this fact.
    I Agree
  3. I do not suffer from medical or skin conditions such as, but not limited to: keloid or hypertrophic scarring, psoriasis at the site of the tattoo or any open wounds or lesions at the site of the tattoo.
    I Agree
  4. I have advised the tattoo artist of any allergies to metals, pigments, latex, soaps, and medications. I acknowledge that it is not possible for the tattoo artist to determine whether I might have an allergic reaction to the tattoo or process involved in the tattoo and further acknowledge that such a reaction is possible.
    I Agree
  5. 5. I have trustfully represented to the tattoo artist that I am over the age of 18 years. I am not under the influence of drugs or alcohol. To my knowledge, I do not have any physical, mental, or medical impairment or disability which might affect my well-being as a direct or indirect result of my decision to have a tattoo done at this time.
    I Agree
  6. I acknowledge that obtaining this tattoo is my choice alone and will result in a permanent change to my appearance, and that no representation has been made to me as to the ability to restore the skin involved in this tattoo to its pre-tattooed condition.
    I Agree
  7. I understand that if I have had a herpetic outbreak in the past that the stress of this procedure may result in a herpetic flare-up.
    I Agree
  8. I do not have mitral valve prolapse or any other heart condition that requires antibiotics before dental work or any other medical procedure.
    I Agree
  9. I have eaten in the last 4 hours.
    I Agree

By my signature below, I certify that if I give false information or produce false documentation stating my name and age to be other than correct, then I am liable for prosecution.


Date: November 30, 2023

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: November 30, 2023





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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