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ROSE GOLD'S TATTOO & PIERCING

I hereby authorize MIKE BIANCO, ORIO GUEVARA, BEN MATTHEWS or representative tattoo artist of Rose Gold's Tattoo & Piercing, to tattoo me. In consideration of doing so, I hereby release said tattoo artist, ROSE GOLD’S TATTOO & PIERCING, their employees, agents, owners, and heirs from all manner of liabilities, claims, actions and demands, in law or equity, whether arising from negligence or any other manner. I have received and read an Aftercare Instruction sheet and assume full responsibility for my own care after each session is completed. I understand that my tattoo will take 2 to 4 weeks to heal, though individual healing times will vary.

-I understand that the needles used for my tattoo are single-use. They have not been used on any other clients. The needles have been autoclaved prior to use and are safely and properly disposed of after each client. -I understand that all equipment used for my tattoo has been sanitized/sterilized prior to use.

-I acknowledge that I am aware certain medical conditions and treatment and/or medications used to treat those conditions may be adversely impacted by the procedure(s) of tattooing. Such medical conditions include, but are not limited to, impaired kidney and/or liver function, diabetes, jaundice, medication containing blood thinners and medication that weaken the immune system.

-I acknowledge that infection is always possible as a result of obtaining a tattoo, especially if I do not take proper care of it. I agree that any touch-up, due to my own negligence, will be done at my own expense.

-I acknowledge it is not reasonably possible for the representatives and employees of this tattoo shop to determine whether I might have an allergic reaction to the pigments or processes used in my tattoo and I agree to accept the risk that such a reaction is possible.

-I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my tattoo.

-The obtaining of this tattoo is by my choice alone. I consent to the application of the tattoo and to any actions or conduct necessary to perform the tattoo.

-I realize that variations in color and design may exist between any tattoo as selected by me and as ultimately applied to my body. I understand that if my skin color is dark, the colors will not appear as bright as they do on light skin.

-I further acknowledge that the tattoo should be considered PERMANENT; that said tattoo can only be removed with a medical procedure; and that any effective removal may leave permanent scarring and disfigurement. 

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information
Are you currently pregnant or breastfeeding?*
Are you currently using or have you recently used medication that contains a controlled substance?*
Have you ever been diagnosed by a medical doctor as to having contracted a communicable disease such as Immune deficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens?*
Have you ever been diagnosed by a medical doctor as having allergies?*
Do you have a heart condition or have had heart surgery?*
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
Are you currently under the influence of any illegal substances?*
Are you currently under the influence of an alcoholic beverage?*
Have you been diagnosed with jaundice within the past twelve months?*
Have you eaten in the last 4 hours?*
Are you currently using any medications that contain blood thinners?*
Are you currently using any medications that weaken the immune system that fights infections?*
I am over the age of 18 years old.*

-If you are currently seeing a doctor for any medical condition, we strongly suggest discussing your intentions with your health care professional. 

-I have read this form and confirm all the information given is correct. I understand that this is a consent form, and I agree to be legally bound by it. 

-I certify under Penalty of Perjury that the above information is true and correct. 


Name that we should call you (if different than ID)

Pronouns that we should use for you

If your tattoo contains letters or numbers please spell them out as you'd like them tattooed. PLEASE DOUBLE & TRIPLE CHECK FOR ACCURACY PRIOR TO BEGINNING THE TATTOO SESSION. THIS IS YOUR RESPONSIBILITY. WE WILL NOT BE LIABLE FOR INACCURACIES OF ANY KIND.
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information
Are you currently pregnant or breastfeeding?*
Are you currently using or have you recently used medication that contains a controlled substance?*
Have you ever been diagnosed by a medical doctor as to having contracted a communicable disease such as Immune deficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens?*
Have you ever been diagnosed by a medical doctor as having allergies?*
Do you have a heart condition or have had heart surgery?*
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
Are you currently under the influence of any illegal substances?*
Are you currently under the influence of an alcoholic beverage?*
Have you been diagnosed with jaundice within the past twelve months?*
Have you eaten in the last 4 hours?*
Are you currently using any medications that contain blood thinners?*
Are you currently using any medications that weaken the immune system that fights infections?*
I am over the age of 18 years old.*

-If you are currently seeing a doctor for any medical condition, we strongly suggest discussing your intentions with your health care professional. 

-I have read this form and confirm all the information given is correct. I understand that this is a consent form, and I agree to be legally bound by it. 

-I certify under Penalty of Perjury that the above information is true and correct. 


Name that we should call you (if different than ID)

Pronouns that we should use for you

If your tattoo contains letters or numbers please spell them out as you'd like them tattooed. PLEASE DOUBLE & TRIPLE CHECK FOR ACCURACY PRIOR TO BEGINNING THE TATTOO SESSION. THIS IS YOUR RESPONSIBILITY. WE WILL NOT BE LIABLE FOR INACCURACIES OF ANY KIND.
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information
Are you currently pregnant or breastfeeding?*
Are you currently using or have you recently used medication that contains a controlled substance?*
Have you ever been diagnosed by a medical doctor as to having contracted a communicable disease such as Immune deficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens?*
Have you ever been diagnosed by a medical doctor as having allergies?*
Do you have a heart condition or have had heart surgery?*
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
Are you currently under the influence of any illegal substances?*
Are you currently under the influence of an alcoholic beverage?*
Have you been diagnosed with jaundice within the past twelve months?*
Have you eaten in the last 4 hours?*
Are you currently using any medications that contain blood thinners?*
Are you currently using any medications that weaken the immune system that fights infections?*
I am over the age of 18 years old.*

-If you are currently seeing a doctor for any medical condition, we strongly suggest discussing your intentions with your health care professional. 

-I have read this form and confirm all the information given is correct. I understand that this is a consent form, and I agree to be legally bound by it. 

-I certify under Penalty of Perjury that the above information is true and correct. 


Name that we should call you (if different than ID)

Pronouns that we should use for you

If your tattoo contains letters or numbers please spell them out as you'd like them tattooed. PLEASE DOUBLE & TRIPLE CHECK FOR ACCURACY PRIOR TO BEGINNING THE TATTOO SESSION. THIS IS YOUR RESPONSIBILITY. WE WILL NOT BE LIABLE FOR INACCURACIES OF ANY KIND.
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information
Are you currently pregnant or breastfeeding?*
Are you currently using or have you recently used medication that contains a controlled substance?*
Have you ever been diagnosed by a medical doctor as to having contracted a communicable disease such as Immune deficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens?*
Have you ever been diagnosed by a medical doctor as having allergies?*
Do you have a heart condition or have had heart surgery?*
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
Are you currently under the influence of any illegal substances?*
Are you currently under the influence of an alcoholic beverage?*
Have you been diagnosed with jaundice within the past twelve months?*
Have you eaten in the last 4 hours?*
Are you currently using any medications that contain blood thinners?*
Are you currently using any medications that weaken the immune system that fights infections?*
I am over the age of 18 years old.*

-If you are currently seeing a doctor for any medical condition, we strongly suggest discussing your intentions with your health care professional. 

-I have read this form and confirm all the information given is correct. I understand that this is a consent form, and I agree to be legally bound by it. 

-I certify under Penalty of Perjury that the above information is true and correct. 


Name that we should call you (if different than ID)

Pronouns that we should use for you

If your tattoo contains letters or numbers please spell them out as you'd like them tattooed. PLEASE DOUBLE & TRIPLE CHECK FOR ACCURACY PRIOR TO BEGINNING THE TATTOO SESSION. THIS IS YOUR RESPONSIBILITY. WE WILL NOT BE LIABLE FOR INACCURACIES OF ANY KIND.
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information
Are you currently pregnant or breastfeeding?*
Are you currently using or have you recently used medication that contains a controlled substance?*
Have you ever been diagnosed by a medical doctor as to having contracted a communicable disease such as Immune deficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens?*
Have you ever been diagnosed by a medical doctor as having allergies?*
Do you have a heart condition or have had heart surgery?*
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
Are you currently under the influence of any illegal substances?*
Are you currently under the influence of an alcoholic beverage?*
Have you been diagnosed with jaundice within the past twelve months?*
Have you eaten in the last 4 hours?*
Are you currently using any medications that contain blood thinners?*
Are you currently using any medications that weaken the immune system that fights infections?*
I am over the age of 18 years old.*

-If you are currently seeing a doctor for any medical condition, we strongly suggest discussing your intentions with your health care professional. 

-I have read this form and confirm all the information given is correct. I understand that this is a consent form, and I agree to be legally bound by it. 

-I certify under Penalty of Perjury that the above information is true and correct. 


Name that we should call you (if different than ID)

Pronouns that we should use for you

If your tattoo contains letters or numbers please spell them out as you'd like them tattooed. PLEASE DOUBLE & TRIPLE CHECK FOR ACCURACY PRIOR TO BEGINNING THE TATTOO SESSION. THIS IS YOUR RESPONSIBILITY. WE WILL NOT BE LIABLE FOR INACCURACIES OF ANY KIND.
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information
Are you currently pregnant or breastfeeding?*
Are you currently using or have you recently used medication that contains a controlled substance?*
Have you ever been diagnosed by a medical doctor as to having contracted a communicable disease such as Immune deficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens?*
Have you ever been diagnosed by a medical doctor as having allergies?*
Do you have a heart condition or have had heart surgery?*
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
Are you currently under the influence of any illegal substances?*
Are you currently under the influence of an alcoholic beverage?*
Have you been diagnosed with jaundice within the past twelve months?*
Have you eaten in the last 4 hours?*
Are you currently using any medications that contain blood thinners?*
Are you currently using any medications that weaken the immune system that fights infections?*
I am over the age of 18 years old.*

-If you are currently seeing a doctor for any medical condition, we strongly suggest discussing your intentions with your health care professional. 

-I have read this form and confirm all the information given is correct. I understand that this is a consent form, and I agree to be legally bound by it. 

-I certify under Penalty of Perjury that the above information is true and correct. 


Name that we should call you (if different than ID)

Pronouns that we should use for you

If your tattoo contains letters or numbers please spell them out as you'd like them tattooed. PLEASE DOUBLE & TRIPLE CHECK FOR ACCURACY PRIOR TO BEGINNING THE TATTOO SESSION. THIS IS YOUR RESPONSIBILITY. WE WILL NOT BE LIABLE FOR INACCURACIES OF ANY KIND.
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information
Are you currently pregnant or breastfeeding?*
Are you currently using or have you recently used medication that contains a controlled substance?*
Have you ever been diagnosed by a medical doctor as to having contracted a communicable disease such as Immune deficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens?*
Have you ever been diagnosed by a medical doctor as having allergies?*
Do you have a heart condition or have had heart surgery?*
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
Are you currently under the influence of any illegal substances?*
Are you currently under the influence of an alcoholic beverage?*
Have you been diagnosed with jaundice within the past twelve months?*
Have you eaten in the last 4 hours?*
Are you currently using any medications that contain blood thinners?*
Are you currently using any medications that weaken the immune system that fights infections?*
I am over the age of 18 years old.*

-If you are currently seeing a doctor for any medical condition, we strongly suggest discussing your intentions with your health care professional. 

-I have read this form and confirm all the information given is correct. I understand that this is a consent form, and I agree to be legally bound by it. 

-I certify under Penalty of Perjury that the above information is true and correct. 


Name that we should call you (if different than ID)

Pronouns that we should use for you

If your tattoo contains letters or numbers please spell them out as you'd like them tattooed. PLEASE DOUBLE & TRIPLE CHECK FOR ACCURACY PRIOR TO BEGINNING THE TATTOO SESSION. THIS IS YOUR RESPONSIBILITY. WE WILL NOT BE LIABLE FOR INACCURACIES OF ANY KIND.
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information
Are you currently pregnant or breastfeeding?*
Are you currently using or have you recently used medication that contains a controlled substance?*
Have you ever been diagnosed by a medical doctor as to having contracted a communicable disease such as Immune deficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens?*
Have you ever been diagnosed by a medical doctor as having allergies?*
Do you have a heart condition or have had heart surgery?*
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
Are you currently under the influence of any illegal substances?*
Are you currently under the influence of an alcoholic beverage?*
Have you been diagnosed with jaundice within the past twelve months?*
Have you eaten in the last 4 hours?*
Are you currently using any medications that contain blood thinners?*
Are you currently using any medications that weaken the immune system that fights infections?*
I am over the age of 18 years old.*

-If you are currently seeing a doctor for any medical condition, we strongly suggest discussing your intentions with your health care professional. 

-I have read this form and confirm all the information given is correct. I understand that this is a consent form, and I agree to be legally bound by it. 

-I certify under Penalty of Perjury that the above information is true and correct. 


Name that we should call you (if different than ID)

Pronouns that we should use for you

If your tattoo contains letters or numbers please spell them out as you'd like them tattooed. PLEASE DOUBLE & TRIPLE CHECK FOR ACCURACY PRIOR TO BEGINNING THE TATTOO SESSION. THIS IS YOUR RESPONSIBILITY. WE WILL NOT BE LIABLE FOR INACCURACIES OF ANY KIND.
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information
Are you currently pregnant or breastfeeding?*
Are you currently using or have you recently used medication that contains a controlled substance?*
Have you ever been diagnosed by a medical doctor as to having contracted a communicable disease such as Immune deficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens?*
Have you ever been diagnosed by a medical doctor as having allergies?*
Do you have a heart condition or have had heart surgery?*
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
Are you currently under the influence of any illegal substances?*
Are you currently under the influence of an alcoholic beverage?*
Have you been diagnosed with jaundice within the past twelve months?*
Have you eaten in the last 4 hours?*
Are you currently using any medications that contain blood thinners?*
Are you currently using any medications that weaken the immune system that fights infections?*
I am over the age of 18 years old.*

-If you are currently seeing a doctor for any medical condition, we strongly suggest discussing your intentions with your health care professional. 

-I have read this form and confirm all the information given is correct. I understand that this is a consent form, and I agree to be legally bound by it. 

-I certify under Penalty of Perjury that the above information is true and correct. 


Name that we should call you (if different than ID)

Pronouns that we should use for you

If your tattoo contains letters or numbers please spell them out as you'd like them tattooed. PLEASE DOUBLE & TRIPLE CHECK FOR ACCURACY PRIOR TO BEGINNING THE TATTOO SESSION. THIS IS YOUR RESPONSIBILITY. WE WILL NOT BE LIABLE FOR INACCURACIES OF ANY KIND.
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information
Are you currently pregnant or breastfeeding?*
Are you currently using or have you recently used medication that contains a controlled substance?*
Have you ever been diagnosed by a medical doctor as to having contracted a communicable disease such as Immune deficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens?*
Have you ever been diagnosed by a medical doctor as having allergies?*
Do you have a heart condition or have had heart surgery?*
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
Are you currently under the influence of any illegal substances?*
Are you currently under the influence of an alcoholic beverage?*
Have you been diagnosed with jaundice within the past twelve months?*
Have you eaten in the last 4 hours?*
Are you currently using any medications that contain blood thinners?*
Are you currently using any medications that weaken the immune system that fights infections?*
I am over the age of 18 years old.*

-If you are currently seeing a doctor for any medical condition, we strongly suggest discussing your intentions with your health care professional. 

-I have read this form and confirm all the information given is correct. I understand that this is a consent form, and I agree to be legally bound by it. 

-I certify under Penalty of Perjury that the above information is true and correct. 


Name that we should call you (if different than ID)

Pronouns that we should use for you

If your tattoo contains letters or numbers please spell them out as you'd like them tattooed. PLEASE DOUBLE & TRIPLE CHECK FOR ACCURACY PRIOR TO BEGINNING THE TATTOO SESSION. THIS IS YOUR RESPONSIBILITY. WE WILL NOT BE LIABLE FOR INACCURACIES OF ANY KIND.
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
A signed copy of this waiver will be sent to the email address you provide.
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
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
Are you currently pregnant or breastfeeding?*
Are you currently using or have you recently used medication that contains a controlled substance?*
Have you ever been diagnosed by a medical doctor as to having contracted a communicable disease such as Immune deficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens?*
Have you ever been diagnosed by a medical doctor as having allergies?*
Do you have a heart condition or have had heart surgery?*
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
Are you currently under the influence of any illegal substances?*
Are you currently under the influence of an alcoholic beverage?*
Have you been diagnosed with jaundice within the past twelve months?*
Have you eaten in the last 4 hours?*
Are you currently using any medications that contain blood thinners?*
Are you currently using any medications that weaken the immune system that fights infections?*
I am over the age of 18 years old.*

-If you are currently seeing a doctor for any medical condition, we strongly suggest discussing your intentions with your health care professional. 

-I have read this form and confirm all the information given is correct. I understand that this is a consent form, and I agree to be legally bound by it. 

-I certify under Penalty of Perjury that the above information is true and correct. 


Name that we should call you (if different than ID)

Pronouns that we should use for you

If your tattoo contains letters or numbers please spell them out as you'd like them tattooed. PLEASE DOUBLE & TRIPLE CHECK FOR ACCURACY PRIOR TO BEGINNING THE TATTOO SESSION. THIS IS YOUR RESPONSIBILITY. WE WILL NOT BE LIABLE FOR INACCURACIES OF ANY KIND.
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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