Loading...

Kyklops LLC

2130 E Carson Street

Pittsburgh, PA 15203

WAIVER, RELEASE, AND CONSENT TO TATTOO 

PLEASE READ AND BE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SIGNING

PLEASE READ EACH PROVISION CHECK THE BOX TO AGREE TO EACH PROVISION OR INITIAL.

In consideration of receiving a tattoo at Kyklops Tattoo (together with its employees, apprentices, contractors and agents, the “Tattoo Studio”), I agree to the following:

 

I am of legal age and am competent to sign this Agreement.

I Agree

 

I agree to comply with all Tattoo Studio policies and rules, including but not limited to proper donning of a face covering, handwashing, hand sanitizing, signage, and instructions. Because the Tattoo Studio is open for use by other individuals, I recognize that I am at higher risk of contracting COVID-19.

I Agree

 

I have been fully informed of the inherent risks, associated with getting a tattoo. 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 associated with getting a tattoo, I still wish to proceed with the tattoo application and I freely accept and expressly assume any and all risks that may arise from tattooing.

I Agree

 

The Tattoo Studio has given me the full opportunity to ask any and all questions about the application of my tattoo and all of my questions have been answered to my total satisfaction.

I Agree

 

The Tattoo Studio has given me instructions on the care of my tattoo while it’s healing, and I understand them and will follow them. It is possible that the tattoo can become infected, particularly if I do not follow the instructions given to me. If any touch-up work to the tattoo is needed due to my own negligence, I agree that the work will be done at my own expense.

I Agree

 

I am not under the influence of alcohol or drugs, and I am voluntarily submitting to be tattooed without duress or coercion. 

I Agree

 

I do not have diabetes, epilepsy, hemophilia, a heart condition, nor do I take blood thinning medication. I do not have any other medical or skin 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 prescribed preventive regimen of antibiotics that is required by my doctor in advance of any invasive procedure such as tattooing or piercing. I am not pregnant or nursing. I do not have a mental impairment that may affect my judgment in getting the tattoo. 

I Agree

 

The Tattoo Studio is NOT responsible for the meaning or spelling of the symbol or text that I have provided to them or chosen from the flash (design) sheets

I Agree

 

Variations in color and design may exist between the tattoo art I have selected and the actual tattoo when it is applied to my body. I also understand that over time, the colors and the clarity of my tattoo will fade due to unprotected exposure to the sun and the naturally occurring dispersion of pigment under the skin. 

I Agree

 

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 to its exact appearance before being tattooed. 

I Agree

 

I release all rights to any photographs taken of me or any minors in my custody and the piercing and give consent in advance to their reproduction in print or electronic form. (If I would prefer not to be photographed, I will indicate my preference in the next section.)

I Agree

 

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, provincial, and local governments recommend social distancing and have, in many locations, prohibited the congregation of groups of people. The Tattoo Studio has put in place preventative measures to reduce the spread of COVID-19; however, the Tattoo Studio cannot guarantee that I will not become infected with COVID-19. Further, having a tattoo performed could increase my risk of contracting COVID-19. As a condition of participation, I release and promise not to sue the Tattoo Studio for any and all claims, demands, causes of action, damage, loss (whether economic or non-economic), expenses, costs, or liability of any nature whatsoever, or for any costs and other expenses, including legal fees, as a result of, or in connection with, my contraction of COVID-19, including if that contraction results from the negligence or gross negligence on the part of the Tattoo Studio. I FREELY ACCEPT AND FULLY ASSUME ALL SUCH RISKS, DANGERS AND HAZARDS AND THE POSSIBILITY OF PERSONAL INJURY, DEATH, PROPERTY DAMAGE AND LOSS RESULTING THEREIN.

I Agree

 

I agree to waive and release to the fullest extent permitted by law the Tattoo 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 the application of my tattoo, whether caused by the negligence or fault of the Tattoo Studio, or otherwise.

I Agree

 

I agree to reimburse the Tattoo Studio for any attorneys’ fees and costs incurred in any legal action I bring against the Tattoo Studio and in which the Tattoo Studio is the prevailing party. The courts of Pennsylvania in Allegheny County shall have personal jurisdiction and venue over me and shall have exclusive jurisdiction for the purpose of litigating any dispute arising out of or related to this agreement.

I Agree

 

If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.

I Agree

 

I have been given adequate opportunity to read and understand this document, that it was not presented to me at the last minute, and I understand that I am signing a legal contract waiving certain rights to recover against the Tattoo Studio. I have read this agreement, I understand it, and I agree to be bound by it.

I Agree

 

I certify under penalty of perjury that the above information is true and correct. I further understand that, if I give false information or produce false documents stating my name and age to be other than what is correct, then I am liable for prosecution. 

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Pronoun (Optional)
He
She
They
Other

if Other:

Please answer the following questions, so we can ensure you the best possible experience.

Have you eaten in the last 4 hours?*
No
Yes
Are you prone to fainting?*
No
Yes
Have you been vaccinated for Covid-19?*
Yes-Partially
Yes-Fully
No
Have you or anyone in your household tested positive for Covid-19?*
No
Yes
Have you had contact with or been in close proximity with anyone who tested positive for COVID-19 or have you worked in a facility with any COVID-19 cases?*
No
Yes
Have you or anyone in your household had either of these respiratory symptoms in the past 10 days?
Cough
Shortness of breath
Have you or anyone in your household had any of the following symptoms in the last 10 days? Please answer honestly, having one or more of these symptoms will not automatically disqualify you from getting tattooed.
Fever
Chills
Headache
Loss of taste
Loss of smell
Diarrhea
Sore throat
Chills
Muscle Pain
Vomiting

If yes, where have you traveled to/from?
Have you traveled within the last 10 days?*
No
Yes
Photographs (optional):
I would prefer NOT to be photographed
Where is your tattoo going?*

In as few words as possible, describe your tattoo. If it is a word, name or number; include it exactly how you want it written/spelled *
Who is doing your tattoo? Please ask if you don't know.*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Pronoun (Optional)
He
She
They
Other

if Other:

Please answer the following questions, so we can ensure you the best possible experience.

Have you eaten in the last 4 hours?*
No
Yes
Are you prone to fainting?*
No
Yes
Have you been vaccinated for Covid-19?*
Yes-Partially
Yes-Fully
No
Have you or anyone in your household tested positive for Covid-19?*
No
Yes
Have you had contact with or been in close proximity with anyone who tested positive for COVID-19 or have you worked in a facility with any COVID-19 cases?*
No
Yes
Have you or anyone in your household had either of these respiratory symptoms in the past 10 days?
Cough
Shortness of breath
Have you or anyone in your household had any of the following symptoms in the last 10 days? Please answer honestly, having one or more of these symptoms will not automatically disqualify you from getting tattooed.
Fever
Chills
Headache
Loss of taste
Loss of smell
Diarrhea
Sore throat
Chills
Muscle Pain
Vomiting

If yes, where have you traveled to/from?
Have you traveled within the last 10 days?*
No
Yes
Photographs (optional):
I would prefer NOT to be photographed
Where is your tattoo going?*

In as few words as possible, describe your tattoo. If it is a word, name or number; include it exactly how you want it written/spelled *
Who is doing your tattoo? Please ask if you don't know.*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Pronoun (Optional)
He
She
They
Other

if Other:

Please answer the following questions, so we can ensure you the best possible experience.

Have you eaten in the last 4 hours?*
No
Yes
Are you prone to fainting?*
No
Yes
Have you been vaccinated for Covid-19?*
Yes-Partially
Yes-Fully
No
Have you or anyone in your household tested positive for Covid-19?*
No
Yes
Have you had contact with or been in close proximity with anyone who tested positive for COVID-19 or have you worked in a facility with any COVID-19 cases?*
No
Yes
Have you or anyone in your household had either of these respiratory symptoms in the past 10 days?
Cough
Shortness of breath
Have you or anyone in your household had any of the following symptoms in the last 10 days? Please answer honestly, having one or more of these symptoms will not automatically disqualify you from getting tattooed.
Fever
Chills
Headache
Loss of taste
Loss of smell
Diarrhea
Sore throat
Chills
Muscle Pain
Vomiting

If yes, where have you traveled to/from?
Have you traveled within the last 10 days?*
No
Yes
Photographs (optional):
I would prefer NOT to be photographed
Where is your tattoo going?*

In as few words as possible, describe your tattoo. If it is a word, name or number; include it exactly how you want it written/spelled *
Who is doing your tattoo? Please ask if you don't know.*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Pronoun (Optional)
He
She
They
Other

if Other:

Please answer the following questions, so we can ensure you the best possible experience.

Have you eaten in the last 4 hours?*
No
Yes
Are you prone to fainting?*
No
Yes
Have you been vaccinated for Covid-19?*
Yes-Partially
Yes-Fully
No
Have you or anyone in your household tested positive for Covid-19?*
No
Yes
Have you had contact with or been in close proximity with anyone who tested positive for COVID-19 or have you worked in a facility with any COVID-19 cases?*
No
Yes
Have you or anyone in your household had either of these respiratory symptoms in the past 10 days?
Cough
Shortness of breath
Have you or anyone in your household had any of the following symptoms in the last 10 days? Please answer honestly, having one or more of these symptoms will not automatically disqualify you from getting tattooed.
Fever
Chills
Headache
Loss of taste
Loss of smell
Diarrhea
Sore throat
Chills
Muscle Pain
Vomiting

If yes, where have you traveled to/from?
Have you traveled within the last 10 days?*
No
Yes
Photographs (optional):
I would prefer NOT to be photographed
Where is your tattoo going?*

In as few words as possible, describe your tattoo. If it is a word, name or number; include it exactly how you want it written/spelled *
Who is doing your tattoo? Please ask if you don't know.*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Pronoun (Optional)
He
She
They
Other

if Other:

Please answer the following questions, so we can ensure you the best possible experience.

Have you eaten in the last 4 hours?*
No
Yes
Are you prone to fainting?*
No
Yes
Have you been vaccinated for Covid-19?*
Yes-Partially
Yes-Fully
No
Have you or anyone in your household tested positive for Covid-19?*
No
Yes
Have you had contact with or been in close proximity with anyone who tested positive for COVID-19 or have you worked in a facility with any COVID-19 cases?*
No
Yes
Have you or anyone in your household had either of these respiratory symptoms in the past 10 days?
Cough
Shortness of breath
Have you or anyone in your household had any of the following symptoms in the last 10 days? Please answer honestly, having one or more of these symptoms will not automatically disqualify you from getting tattooed.
Fever
Chills
Headache
Loss of taste
Loss of smell
Diarrhea
Sore throat
Chills
Muscle Pain
Vomiting

If yes, where have you traveled to/from?
Have you traveled within the last 10 days?*
No
Yes
Photographs (optional):
I would prefer NOT to be photographed
Where is your tattoo going?*

In as few words as possible, describe your tattoo. If it is a word, name or number; include it exactly how you want it written/spelled *
Who is doing your tattoo? Please ask if you don't know.*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Pronoun (Optional)
He
She
They
Other

if Other:

Please answer the following questions, so we can ensure you the best possible experience.

Have you eaten in the last 4 hours?*
No
Yes
Are you prone to fainting?*
No
Yes
Have you been vaccinated for Covid-19?*
Yes-Partially
Yes-Fully
No
Have you or anyone in your household tested positive for Covid-19?*
No
Yes
Have you had contact with or been in close proximity with anyone who tested positive for COVID-19 or have you worked in a facility with any COVID-19 cases?*
No
Yes
Have you or anyone in your household had either of these respiratory symptoms in the past 10 days?
Cough
Shortness of breath
Have you or anyone in your household had any of the following symptoms in the last 10 days? Please answer honestly, having one or more of these symptoms will not automatically disqualify you from getting tattooed.
Fever
Chills
Headache
Loss of taste
Loss of smell
Diarrhea
Sore throat
Chills
Muscle Pain
Vomiting

If yes, where have you traveled to/from?
Have you traveled within the last 10 days?*
No
Yes
Photographs (optional):
I would prefer NOT to be photographed
Where is your tattoo going?*

In as few words as possible, describe your tattoo. If it is a word, name or number; include it exactly how you want it written/spelled *
Who is doing your tattoo? Please ask if you don't know.*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Pronoun (Optional)
He
She
They
Other

if Other:

Please answer the following questions, so we can ensure you the best possible experience.

Have you eaten in the last 4 hours?*
No
Yes
Are you prone to fainting?*
No
Yes
Have you been vaccinated for Covid-19?*
Yes-Partially
Yes-Fully
No
Have you or anyone in your household tested positive for Covid-19?*
No
Yes
Have you had contact with or been in close proximity with anyone who tested positive for COVID-19 or have you worked in a facility with any COVID-19 cases?*
No
Yes
Have you or anyone in your household had either of these respiratory symptoms in the past 10 days?
Cough
Shortness of breath
Have you or anyone in your household had any of the following symptoms in the last 10 days? Please answer honestly, having one or more of these symptoms will not automatically disqualify you from getting tattooed.
Fever
Chills
Headache
Loss of taste
Loss of smell
Diarrhea
Sore throat
Chills
Muscle Pain
Vomiting

If yes, where have you traveled to/from?
Have you traveled within the last 10 days?*
No
Yes
Photographs (optional):
I would prefer NOT to be photographed
Where is your tattoo going?*

In as few words as possible, describe your tattoo. If it is a word, name or number; include it exactly how you want it written/spelled *
Who is doing your tattoo? Please ask if you don't know.*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Pronoun (Optional)
He
She
They
Other

if Other:

Please answer the following questions, so we can ensure you the best possible experience.

Have you eaten in the last 4 hours?*
No
Yes
Are you prone to fainting?*
No
Yes
Have you been vaccinated for Covid-19?*
Yes-Partially
Yes-Fully
No
Have you or anyone in your household tested positive for Covid-19?*
No
Yes
Have you had contact with or been in close proximity with anyone who tested positive for COVID-19 or have you worked in a facility with any COVID-19 cases?*
No
Yes
Have you or anyone in your household had either of these respiratory symptoms in the past 10 days?
Cough
Shortness of breath
Have you or anyone in your household had any of the following symptoms in the last 10 days? Please answer honestly, having one or more of these symptoms will not automatically disqualify you from getting tattooed.
Fever
Chills
Headache
Loss of taste
Loss of smell
Diarrhea
Sore throat
Chills
Muscle Pain
Vomiting

If yes, where have you traveled to/from?
Have you traveled within the last 10 days?*
No
Yes
Photographs (optional):
I would prefer NOT to be photographed
Where is your tattoo going?*

In as few words as possible, describe your tattoo. If it is a word, name or number; include it exactly how you want it written/spelled *
Who is doing your tattoo? Please ask if you don't know.*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Pronoun (Optional)
He
She
They
Other

if Other:

Please answer the following questions, so we can ensure you the best possible experience.

Have you eaten in the last 4 hours?*
No
Yes
Are you prone to fainting?*
No
Yes
Have you been vaccinated for Covid-19?*
Yes-Partially
Yes-Fully
No
Have you or anyone in your household tested positive for Covid-19?*
No
Yes
Have you had contact with or been in close proximity with anyone who tested positive for COVID-19 or have you worked in a facility with any COVID-19 cases?*
No
Yes
Have you or anyone in your household had either of these respiratory symptoms in the past 10 days?
Cough
Shortness of breath
Have you or anyone in your household had any of the following symptoms in the last 10 days? Please answer honestly, having one or more of these symptoms will not automatically disqualify you from getting tattooed.
Fever
Chills
Headache
Loss of taste
Loss of smell
Diarrhea
Sore throat
Chills
Muscle Pain
Vomiting

If yes, where have you traveled to/from?
Have you traveled within the last 10 days?*
No
Yes
Photographs (optional):
I would prefer NOT to be photographed
Where is your tattoo going?*

In as few words as possible, describe your tattoo. If it is a word, name or number; include it exactly how you want it written/spelled *
Who is doing your tattoo? Please ask if you don't know.*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Pronoun (Optional)
He
She
They
Other

if Other:

Please answer the following questions, so we can ensure you the best possible experience.

Have you eaten in the last 4 hours?*
No
Yes
Are you prone to fainting?*
No
Yes
Have you been vaccinated for Covid-19?*
Yes-Partially
Yes-Fully
No
Have you or anyone in your household tested positive for Covid-19?*
No
Yes
Have you had contact with or been in close proximity with anyone who tested positive for COVID-19 or have you worked in a facility with any COVID-19 cases?*
No
Yes
Have you or anyone in your household had either of these respiratory symptoms in the past 10 days?
Cough
Shortness of breath
Have you or anyone in your household had any of the following symptoms in the last 10 days? Please answer honestly, having one or more of these symptoms will not automatically disqualify you from getting tattooed.
Fever
Chills
Headache
Loss of taste
Loss of smell
Diarrhea
Sore throat
Chills
Muscle Pain
Vomiting

If yes, where have you traveled to/from?
Have you traveled within the last 10 days?*
No
Yes
Photographs (optional):
I would prefer NOT to be photographed
Where is your tattoo going?*

In as few words as possible, describe your tattoo. If it is a word, name or number; include it exactly how you want it written/spelled *
Who is doing your tattoo? Please ask if you don't know.*
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
Pronoun (Optional)
He
She
They
Other

if Other:

Please answer the following questions, so we can ensure you the best possible experience.

Have you eaten in the last 4 hours?*
No
Yes
Are you prone to fainting?*
No
Yes
Have you been vaccinated for Covid-19?*
Yes-Partially
Yes-Fully
No
Have you or anyone in your household tested positive for Covid-19?*
No
Yes
Have you had contact with or been in close proximity with anyone who tested positive for COVID-19 or have you worked in a facility with any COVID-19 cases?*
No
Yes
Have you or anyone in your household had either of these respiratory symptoms in the past 10 days?
Cough
Shortness of breath
Have you or anyone in your household had any of the following symptoms in the last 10 days? Please answer honestly, having one or more of these symptoms will not automatically disqualify you from getting tattooed.
Fever
Chills
Headache
Loss of taste
Loss of smell
Diarrhea
Sore throat
Chills
Muscle Pain
Vomiting

If yes, where have you traveled to/from?
Have you traveled within the last 10 days?*
No
Yes
Photographs (optional):
I would prefer NOT to be photographed
Where is your tattoo going?*

In as few words as possible, describe your tattoo. If it is a word, name or number; include it exactly how you want it written/spelled *
Who is doing your tattoo? Please ask if you don't know.*
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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!