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

I further acknowledge that the tattoo and/or brand should be considered permanent; that said tattoo and/or brand can only be removed with a surgical procedure; and that any effective removal may leave permanent scarring and disfigurement.

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

Today's Date: November 25, 2020

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
PROCEDURE(S) TO BE PERFORMED (CHECK ALL THAT APPLY)
TATTOO
BODY PIERCING
BRAND

PART OF BODY TO BE PIERCED
Are you currently or have you ever used medications that contain a controlled substance?*
No
Yes
Have you ever been diagnosed by a medical doctor as to having contracted communicable disease such as Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and/or other blood borne pathogens?*
No
Yes

If so, when?
Have you ever been diagnosed by a medical doctor as having allergies?*
No
Yes
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
No
Yes
Are you currently under the influence of any illegal substances?*
No
Yes
Are you currently under the influence of an alcoholic beverage?*
No
Yes
Have you been diagnosed with jaundice within the past twelve months?*
No
Yes
Are you currently using any medications that contain blood thinners?*
No
Yes
Are you currently using any medications that weaken the immune system that fights infections?*
No
Yes
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
PROCEDURE(S) TO BE PERFORMED (CHECK ALL THAT APPLY)
TATTOO
BODY PIERCING
BRAND

PART OF BODY TO BE PIERCED
Are you currently or have you ever used medications that contain a controlled substance?*
No
Yes
Have you ever been diagnosed by a medical doctor as to having contracted communicable disease such as Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and/or other blood borne pathogens?*
No
Yes

If so, when?
Have you ever been diagnosed by a medical doctor as having allergies?*
No
Yes
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
No
Yes
Are you currently under the influence of any illegal substances?*
No
Yes
Are you currently under the influence of an alcoholic beverage?*
No
Yes
Have you been diagnosed with jaundice within the past twelve months?*
No
Yes
Are you currently using any medications that contain blood thinners?*
No
Yes
Are you currently using any medications that weaken the immune system that fights infections?*
No
Yes
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
PROCEDURE(S) TO BE PERFORMED (CHECK ALL THAT APPLY)
TATTOO
BODY PIERCING
BRAND

PART OF BODY TO BE PIERCED
Are you currently or have you ever used medications that contain a controlled substance?*
No
Yes
Have you ever been diagnosed by a medical doctor as to having contracted communicable disease such as Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and/or other blood borne pathogens?*
No
Yes

If so, when?
Have you ever been diagnosed by a medical doctor as having allergies?*
No
Yes
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
No
Yes
Are you currently under the influence of any illegal substances?*
No
Yes
Are you currently under the influence of an alcoholic beverage?*
No
Yes
Have you been diagnosed with jaundice within the past twelve months?*
No
Yes
Are you currently using any medications that contain blood thinners?*
No
Yes
Are you currently using any medications that weaken the immune system that fights infections?*
No
Yes
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
PROCEDURE(S) TO BE PERFORMED (CHECK ALL THAT APPLY)
TATTOO
BODY PIERCING
BRAND

PART OF BODY TO BE PIERCED
Are you currently or have you ever used medications that contain a controlled substance?*
No
Yes
Have you ever been diagnosed by a medical doctor as to having contracted communicable disease such as Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and/or other blood borne pathogens?*
No
Yes

If so, when?
Have you ever been diagnosed by a medical doctor as having allergies?*
No
Yes
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
No
Yes
Are you currently under the influence of any illegal substances?*
No
Yes
Are you currently under the influence of an alcoholic beverage?*
No
Yes
Have you been diagnosed with jaundice within the past twelve months?*
No
Yes
Are you currently using any medications that contain blood thinners?*
No
Yes
Are you currently using any medications that weaken the immune system that fights infections?*
No
Yes
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
PROCEDURE(S) TO BE PERFORMED (CHECK ALL THAT APPLY)
TATTOO
BODY PIERCING
BRAND

PART OF BODY TO BE PIERCED
Are you currently or have you ever used medications that contain a controlled substance?*
No
Yes
Have you ever been diagnosed by a medical doctor as to having contracted communicable disease such as Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and/or other blood borne pathogens?*
No
Yes

If so, when?
Have you ever been diagnosed by a medical doctor as having allergies?*
No
Yes
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
No
Yes
Are you currently under the influence of any illegal substances?*
No
Yes
Are you currently under the influence of an alcoholic beverage?*
No
Yes
Have you been diagnosed with jaundice within the past twelve months?*
No
Yes
Are you currently using any medications that contain blood thinners?*
No
Yes
Are you currently using any medications that weaken the immune system that fights infections?*
No
Yes
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
PROCEDURE(S) TO BE PERFORMED (CHECK ALL THAT APPLY)
TATTOO
BODY PIERCING
BRAND

PART OF BODY TO BE PIERCED
Are you currently or have you ever used medications that contain a controlled substance?*
No
Yes
Have you ever been diagnosed by a medical doctor as to having contracted communicable disease such as Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and/or other blood borne pathogens?*
No
Yes

If so, when?
Have you ever been diagnosed by a medical doctor as having allergies?*
No
Yes
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
No
Yes
Are you currently under the influence of any illegal substances?*
No
Yes
Are you currently under the influence of an alcoholic beverage?*
No
Yes
Have you been diagnosed with jaundice within the past twelve months?*
No
Yes
Are you currently using any medications that contain blood thinners?*
No
Yes
Are you currently using any medications that weaken the immune system that fights infections?*
No
Yes
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
PROCEDURE(S) TO BE PERFORMED (CHECK ALL THAT APPLY)
TATTOO
BODY PIERCING
BRAND

PART OF BODY TO BE PIERCED
Are you currently or have you ever used medications that contain a controlled substance?*
No
Yes
Have you ever been diagnosed by a medical doctor as to having contracted communicable disease such as Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and/or other blood borne pathogens?*
No
Yes

If so, when?
Have you ever been diagnosed by a medical doctor as having allergies?*
No
Yes
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
No
Yes
Are you currently under the influence of any illegal substances?*
No
Yes
Are you currently under the influence of an alcoholic beverage?*
No
Yes
Have you been diagnosed with jaundice within the past twelve months?*
No
Yes
Are you currently using any medications that contain blood thinners?*
No
Yes
Are you currently using any medications that weaken the immune system that fights infections?*
No
Yes
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
PROCEDURE(S) TO BE PERFORMED (CHECK ALL THAT APPLY)
TATTOO
BODY PIERCING
BRAND

PART OF BODY TO BE PIERCED
Are you currently or have you ever used medications that contain a controlled substance?*
No
Yes
Have you ever been diagnosed by a medical doctor as to having contracted communicable disease such as Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and/or other blood borne pathogens?*
No
Yes

If so, when?
Have you ever been diagnosed by a medical doctor as having allergies?*
No
Yes
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
No
Yes
Are you currently under the influence of any illegal substances?*
No
Yes
Are you currently under the influence of an alcoholic beverage?*
No
Yes
Have you been diagnosed with jaundice within the past twelve months?*
No
Yes
Are you currently using any medications that contain blood thinners?*
No
Yes
Are you currently using any medications that weaken the immune system that fights infections?*
No
Yes
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
PROCEDURE(S) TO BE PERFORMED (CHECK ALL THAT APPLY)
TATTOO
BODY PIERCING
BRAND

PART OF BODY TO BE PIERCED
Are you currently or have you ever used medications that contain a controlled substance?*
No
Yes
Have you ever been diagnosed by a medical doctor as to having contracted communicable disease such as Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and/or other blood borne pathogens?*
No
Yes

If so, when?
Have you ever been diagnosed by a medical doctor as having allergies?*
No
Yes
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
No
Yes
Are you currently under the influence of any illegal substances?*
No
Yes
Are you currently under the influence of an alcoholic beverage?*
No
Yes
Have you been diagnosed with jaundice within the past twelve months?*
No
Yes
Are you currently using any medications that contain blood thinners?*
No
Yes
Are you currently using any medications that weaken the immune system that fights infections?*
No
Yes
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
PROCEDURE(S) TO BE PERFORMED (CHECK ALL THAT APPLY)
TATTOO
BODY PIERCING
BRAND

PART OF BODY TO BE PIERCED
Are you currently or have you ever used medications that contain a controlled substance?*
No
Yes
Have you ever been diagnosed by a medical doctor as to having contracted communicable disease such as Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and/or other blood borne pathogens?*
No
Yes

If so, when?
Have you ever been diagnosed by a medical doctor as having allergies?*
No
Yes
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
No
Yes
Are you currently under the influence of any illegal substances?*
No
Yes
Are you currently under the influence of an alcoholic beverage?*
No
Yes
Have you been diagnosed with jaundice within the past twelve months?*
No
Yes
Are you currently using any medications that contain blood thinners?*
No
Yes
Are you currently using any medications that weaken the immune system that fights infections?*
No
Yes
Participant'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*
Check to receive information, news, and discounts by e-mail.
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
PROCEDURE(S) TO BE PERFORMED (CHECK ALL THAT APPLY)
TATTOO
BODY PIERCING
BRAND

PART OF BODY TO BE PIERCED
Are you currently or have you ever used medications that contain a controlled substance?*
No
Yes
Have you ever been diagnosed by a medical doctor as to having contracted communicable disease such as Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and/or other blood borne pathogens?*
No
Yes

If so, when?
Have you ever been diagnosed by a medical doctor as having allergies?*
No
Yes
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
No
Yes
Are you currently under the influence of any illegal substances?*
No
Yes
Are you currently under the influence of an alcoholic beverage?*
No
Yes
Have you been diagnosed with jaundice within the past twelve months?*
No
Yes
Are you currently using any medications that contain blood thinners?*
No
Yes
Are you currently using any medications that weaken the immune system that fights infections?*
No
Yes
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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