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Tiger Shark Tattoo Studio                                                                                     
861 NW Federal Hwy Stuart , FL     7722324141

 

 

Medical Disclosure and Release Form

I hereby release and discharge Tiger Shark Tattoo Shop and its employees from any type of negligence, liability, claim, action, demand, and compensation in law and in equity, which I have or might have, now and hereafter; by reason of my request to be tattooed. I also specifically release and forever discharge Tiger Shark Tattoo Shop and its employees and its agents, for any and all loss or damage on account of injury to my person or property caused by Tiger Shark Tattoo Shop, otherwise; by reason of my request to be tattooed. I give permission to copyright and/or publish photographs of myself with or without my name in any such manner as deemed proper to their use. I realize that misrepresentation or falsification of information provided by me is a crime and is subject to prosecution. I further certify that I am over the age of eighteen and am not intoxicated or under the influence of any narcotic substance and made this statement entirely of free will and sound mind. I acknowledge that a tattoo is a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove my tattoo. 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 acknowledge that infection is always possible as a result of the obtaining of a tattoo, particularly in the event that I do not take proper care of my tattoo. I also acknowledge that I have received aftercare instructions for my tattoo today. This is a legal binding contract.

Today's date: June 21, 2024

First Client's Name

First Name*

Last Name*

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

Age:

Occupation:

Type of Design:
Artist's Name:*

If Guest Artist, please list their name:

Location on Body:
First Time:*
No
Yes

*Please note the following information will not be disclosed. It is for the safety of you and your artist


Physicians Name:

Phone:

Do you have allergies to the following? Please answer Y / N 

Antibiotics*
No
Yes
Soaps*
No
Yes
Metals*
No
Yes
Latex*
No
Yes
Alcohol*
No
Yes
Cosmetics*
No
Yes

Do you currently have or have you ever had any communicable disease(s) or infections? Please answer Y / N

Hepatitis*
No
Yes
Herpes*
No
Yes
Gonorrhea*
No
Yes
HIV*
No
Yes
Syphilis*
No
Yes
Staph*
No
Yes
Tuberculosis*
No
Yes

Other:
Are you currently taking any medication?*
No
Yes

If yes, what?

Please answer the following in regards to your medical history: Please answer Y / N 

Heart Condition*
No
Yes
Pregnant*
No
Yes
Skin Condition*
No
Yes
Epileptic*
No
Yes
Diabetic*
No
Yes
Fainting/Dizziness*
No
Yes
Subject to Rashes*
No
Yes
High Blood Pressure*
No
Yes
IV Drugs*
No
Yes

Other:

COVID-19 Screening Questions - Please answer Y / N for each question: 

In the last 2 weeks have you: 

Been tested for COVID-19?*
No
Yes
Had flu-like symptoms such as a fever, chills, nausea, vomiting, diarrhea, shortness of breath, sore throat, muscle aches, or loss of taste or smell?*
No
Yes
Been in contact with anyone who has tested positive for COVID-19 or has flu-like symptoms?*
No
Yes
Traveled outside of the United States or traveled on a cruise ship?*
No
Yes
First Client's Signature*
Second Client's Name

First Name*

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

Age:

Occupation:

Type of Design:
Artist's Name:*

If Guest Artist, please list their name:

Location on Body:
First Time:*
No
Yes

*Please note the following information will not be disclosed. It is for the safety of you and your artist


Physicians Name:

Phone:

Do you have allergies to the following? Please answer Y / N 

Antibiotics*
No
Yes
Soaps*
No
Yes
Metals*
No
Yes
Latex*
No
Yes
Alcohol*
No
Yes
Cosmetics*
No
Yes

Do you currently have or have you ever had any communicable disease(s) or infections? Please answer Y / N

Hepatitis*
No
Yes
Herpes*
No
Yes
Gonorrhea*
No
Yes
HIV*
No
Yes
Syphilis*
No
Yes
Staph*
No
Yes
Tuberculosis*
No
Yes

Other:
Are you currently taking any medication?*
No
Yes

If yes, what?

Please answer the following in regards to your medical history: Please answer Y / N 

Heart Condition*
No
Yes
Pregnant*
No
Yes
Skin Condition*
No
Yes
Epileptic*
No
Yes
Diabetic*
No
Yes
Fainting/Dizziness*
No
Yes
Subject to Rashes*
No
Yes
High Blood Pressure*
No
Yes
IV Drugs*
No
Yes

Other:

COVID-19 Screening Questions - Please answer Y / N for each question: 

In the last 2 weeks have you: 

Been tested for COVID-19?*
No
Yes
Had flu-like symptoms such as a fever, chills, nausea, vomiting, diarrhea, shortness of breath, sore throat, muscle aches, or loss of taste or smell?*
No
Yes
Been in contact with anyone who has tested positive for COVID-19 or has flu-like symptoms?*
No
Yes
Traveled outside of the United States or traveled on a cruise ship?*
No
Yes
Third Client's Name

First Name*

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

Age:

Occupation:

Type of Design:
Artist's Name:*

If Guest Artist, please list their name:

Location on Body:
First Time:*
No
Yes

*Please note the following information will not be disclosed. It is for the safety of you and your artist


Physicians Name:

Phone:

Do you have allergies to the following? Please answer Y / N 

Antibiotics*
No
Yes
Soaps*
No
Yes
Metals*
No
Yes
Latex*
No
Yes
Alcohol*
No
Yes
Cosmetics*
No
Yes

Do you currently have or have you ever had any communicable disease(s) or infections? Please answer Y / N

Hepatitis*
No
Yes
Herpes*
No
Yes
Gonorrhea*
No
Yes
HIV*
No
Yes
Syphilis*
No
Yes
Staph*
No
Yes
Tuberculosis*
No
Yes

Other:
Are you currently taking any medication?*
No
Yes

If yes, what?

Please answer the following in regards to your medical history: Please answer Y / N 

Heart Condition*
No
Yes
Pregnant*
No
Yes
Skin Condition*
No
Yes
Epileptic*
No
Yes
Diabetic*
No
Yes
Fainting/Dizziness*
No
Yes
Subject to Rashes*
No
Yes
High Blood Pressure*
No
Yes
IV Drugs*
No
Yes

Other:

COVID-19 Screening Questions - Please answer Y / N for each question: 

In the last 2 weeks have you: 

Been tested for COVID-19?*
No
Yes
Had flu-like symptoms such as a fever, chills, nausea, vomiting, diarrhea, shortness of breath, sore throat, muscle aches, or loss of taste or smell?*
No
Yes
Been in contact with anyone who has tested positive for COVID-19 or has flu-like symptoms?*
No
Yes
Traveled outside of the United States or traveled on a cruise ship?*
No
Yes
Fourth Client's Name

First Name*

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

Age:

Occupation:

Type of Design:
Artist's Name:*

If Guest Artist, please list their name:

Location on Body:
First Time:*
No
Yes

*Please note the following information will not be disclosed. It is for the safety of you and your artist


Physicians Name:

Phone:

Do you have allergies to the following? Please answer Y / N 

Antibiotics*
No
Yes
Soaps*
No
Yes
Metals*
No
Yes
Latex*
No
Yes
Alcohol*
No
Yes
Cosmetics*
No
Yes

Do you currently have or have you ever had any communicable disease(s) or infections? Please answer Y / N

Hepatitis*
No
Yes
Herpes*
No
Yes
Gonorrhea*
No
Yes
HIV*
No
Yes
Syphilis*
No
Yes
Staph*
No
Yes
Tuberculosis*
No
Yes

Other:
Are you currently taking any medication?*
No
Yes

If yes, what?

Please answer the following in regards to your medical history: Please answer Y / N 

Heart Condition*
No
Yes
Pregnant*
No
Yes
Skin Condition*
No
Yes
Epileptic*
No
Yes
Diabetic*
No
Yes
Fainting/Dizziness*
No
Yes
Subject to Rashes*
No
Yes
High Blood Pressure*
No
Yes
IV Drugs*
No
Yes

Other:

COVID-19 Screening Questions - Please answer Y / N for each question: 

In the last 2 weeks have you: 

Been tested for COVID-19?*
No
Yes
Had flu-like symptoms such as a fever, chills, nausea, vomiting, diarrhea, shortness of breath, sore throat, muscle aches, or loss of taste or smell?*
No
Yes
Been in contact with anyone who has tested positive for COVID-19 or has flu-like symptoms?*
No
Yes
Traveled outside of the United States or traveled on a cruise ship?*
No
Yes
Fifth Client's Name

First Name*

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

Age:

Occupation:

Type of Design:
Artist's Name:*

If Guest Artist, please list their name:

Location on Body:
First Time:*
No
Yes

*Please note the following information will not be disclosed. It is for the safety of you and your artist


Physicians Name:

Phone:

Do you have allergies to the following? Please answer Y / N 

Antibiotics*
No
Yes
Soaps*
No
Yes
Metals*
No
Yes
Latex*
No
Yes
Alcohol*
No
Yes
Cosmetics*
No
Yes

Do you currently have or have you ever had any communicable disease(s) or infections? Please answer Y / N

Hepatitis*
No
Yes
Herpes*
No
Yes
Gonorrhea*
No
Yes
HIV*
No
Yes
Syphilis*
No
Yes
Staph*
No
Yes
Tuberculosis*
No
Yes

Other:
Are you currently taking any medication?*
No
Yes

If yes, what?

Please answer the following in regards to your medical history: Please answer Y / N 

Heart Condition*
No
Yes
Pregnant*
No
Yes
Skin Condition*
No
Yes
Epileptic*
No
Yes
Diabetic*
No
Yes
Fainting/Dizziness*
No
Yes
Subject to Rashes*
No
Yes
High Blood Pressure*
No
Yes
IV Drugs*
No
Yes

Other:

COVID-19 Screening Questions - Please answer Y / N for each question: 

In the last 2 weeks have you: 

Been tested for COVID-19?*
No
Yes
Had flu-like symptoms such as a fever, chills, nausea, vomiting, diarrhea, shortness of breath, sore throat, muscle aches, or loss of taste or smell?*
No
Yes
Been in contact with anyone who has tested positive for COVID-19 or has flu-like symptoms?*
No
Yes
Traveled outside of the United States or traveled on a cruise ship?*
No
Yes
Sixth Client's Name

First Name*

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

Age:

Occupation:

Type of Design:
Artist's Name:*

If Guest Artist, please list their name:

Location on Body:
First Time:*
No
Yes

*Please note the following information will not be disclosed. It is for the safety of you and your artist


Physicians Name:

Phone:

Do you have allergies to the following? Please answer Y / N 

Antibiotics*
No
Yes
Soaps*
No
Yes
Metals*
No
Yes
Latex*
No
Yes
Alcohol*
No
Yes
Cosmetics*
No
Yes

Do you currently have or have you ever had any communicable disease(s) or infections? Please answer Y / N

Hepatitis*
No
Yes
Herpes*
No
Yes
Gonorrhea*
No
Yes
HIV*
No
Yes
Syphilis*
No
Yes
Staph*
No
Yes
Tuberculosis*
No
Yes

Other:
Are you currently taking any medication?*
No
Yes

If yes, what?

Please answer the following in regards to your medical history: Please answer Y / N 

Heart Condition*
No
Yes
Pregnant*
No
Yes
Skin Condition*
No
Yes
Epileptic*
No
Yes
Diabetic*
No
Yes
Fainting/Dizziness*
No
Yes
Subject to Rashes*
No
Yes
High Blood Pressure*
No
Yes
IV Drugs*
No
Yes

Other:

COVID-19 Screening Questions - Please answer Y / N for each question: 

In the last 2 weeks have you: 

Been tested for COVID-19?*
No
Yes
Had flu-like symptoms such as a fever, chills, nausea, vomiting, diarrhea, shortness of breath, sore throat, muscle aches, or loss of taste or smell?*
No
Yes
Been in contact with anyone who has tested positive for COVID-19 or has flu-like symptoms?*
No
Yes
Traveled outside of the United States or traveled on a cruise ship?*
No
Yes
Seventh Client's Name

First Name*

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

Age:

Occupation:

Type of Design:
Artist's Name:*

If Guest Artist, please list their name:

Location on Body:
First Time:*
No
Yes

*Please note the following information will not be disclosed. It is for the safety of you and your artist


Physicians Name:

Phone:

Do you have allergies to the following? Please answer Y / N 

Antibiotics*
No
Yes
Soaps*
No
Yes
Metals*
No
Yes
Latex*
No
Yes
Alcohol*
No
Yes
Cosmetics*
No
Yes

Do you currently have or have you ever had any communicable disease(s) or infections? Please answer Y / N

Hepatitis*
No
Yes
Herpes*
No
Yes
Gonorrhea*
No
Yes
HIV*
No
Yes
Syphilis*
No
Yes
Staph*
No
Yes
Tuberculosis*
No
Yes

Other:
Are you currently taking any medication?*
No
Yes

If yes, what?

Please answer the following in regards to your medical history: Please answer Y / N 

Heart Condition*
No
Yes
Pregnant*
No
Yes
Skin Condition*
No
Yes
Epileptic*
No
Yes
Diabetic*
No
Yes
Fainting/Dizziness*
No
Yes
Subject to Rashes*
No
Yes
High Blood Pressure*
No
Yes
IV Drugs*
No
Yes

Other:

COVID-19 Screening Questions - Please answer Y / N for each question: 

In the last 2 weeks have you: 

Been tested for COVID-19?*
No
Yes
Had flu-like symptoms such as a fever, chills, nausea, vomiting, diarrhea, shortness of breath, sore throat, muscle aches, or loss of taste or smell?*
No
Yes
Been in contact with anyone who has tested positive for COVID-19 or has flu-like symptoms?*
No
Yes
Traveled outside of the United States or traveled on a cruise ship?*
No
Yes
Eighth Client's Name

First Name*

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

Age:

Occupation:

Type of Design:
Artist's Name:*

If Guest Artist, please list their name:

Location on Body:
First Time:*
No
Yes

*Please note the following information will not be disclosed. It is for the safety of you and your artist


Physicians Name:

Phone:

Do you have allergies to the following? Please answer Y / N 

Antibiotics*
No
Yes
Soaps*
No
Yes
Metals*
No
Yes
Latex*
No
Yes
Alcohol*
No
Yes
Cosmetics*
No
Yes

Do you currently have or have you ever had any communicable disease(s) or infections? Please answer Y / N

Hepatitis*
No
Yes
Herpes*
No
Yes
Gonorrhea*
No
Yes
HIV*
No
Yes
Syphilis*
No
Yes
Staph*
No
Yes
Tuberculosis*
No
Yes

Other:
Are you currently taking any medication?*
No
Yes

If yes, what?

Please answer the following in regards to your medical history: Please answer Y / N 

Heart Condition*
No
Yes
Pregnant*
No
Yes
Skin Condition*
No
Yes
Epileptic*
No
Yes
Diabetic*
No
Yes
Fainting/Dizziness*
No
Yes
Subject to Rashes*
No
Yes
High Blood Pressure*
No
Yes
IV Drugs*
No
Yes

Other:

COVID-19 Screening Questions - Please answer Y / N for each question: 

In the last 2 weeks have you: 

Been tested for COVID-19?*
No
Yes
Had flu-like symptoms such as a fever, chills, nausea, vomiting, diarrhea, shortness of breath, sore throat, muscle aches, or loss of taste or smell?*
No
Yes
Been in contact with anyone who has tested positive for COVID-19 or has flu-like symptoms?*
No
Yes
Traveled outside of the United States or traveled on a cruise ship?*
No
Yes
Ninth Client's Name

First Name*

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

Age:

Occupation:

Type of Design:
Artist's Name:*

If Guest Artist, please list their name:

Location on Body:
First Time:*
No
Yes

*Please note the following information will not be disclosed. It is for the safety of you and your artist


Physicians Name:

Phone:

Do you have allergies to the following? Please answer Y / N 

Antibiotics*
No
Yes
Soaps*
No
Yes
Metals*
No
Yes
Latex*
No
Yes
Alcohol*
No
Yes
Cosmetics*
No
Yes

Do you currently have or have you ever had any communicable disease(s) or infections? Please answer Y / N

Hepatitis*
No
Yes
Herpes*
No
Yes
Gonorrhea*
No
Yes
HIV*
No
Yes
Syphilis*
No
Yes
Staph*
No
Yes
Tuberculosis*
No
Yes

Other:
Are you currently taking any medication?*
No
Yes

If yes, what?

Please answer the following in regards to your medical history: Please answer Y / N 

Heart Condition*
No
Yes
Pregnant*
No
Yes
Skin Condition*
No
Yes
Epileptic*
No
Yes
Diabetic*
No
Yes
Fainting/Dizziness*
No
Yes
Subject to Rashes*
No
Yes
High Blood Pressure*
No
Yes
IV Drugs*
No
Yes

Other:

COVID-19 Screening Questions - Please answer Y / N for each question: 

In the last 2 weeks have you: 

Been tested for COVID-19?*
No
Yes
Had flu-like symptoms such as a fever, chills, nausea, vomiting, diarrhea, shortness of breath, sore throat, muscle aches, or loss of taste or smell?*
No
Yes
Been in contact with anyone who has tested positive for COVID-19 or has flu-like symptoms?*
No
Yes
Traveled outside of the United States or traveled on a cruise ship?*
No
Yes
Tenth Client's Name

First Name*

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

Age:

Occupation:

Type of Design:
Artist's Name:*

If Guest Artist, please list their name:

Location on Body:
First Time:*
No
Yes

*Please note the following information will not be disclosed. It is for the safety of you and your artist


Physicians Name:

Phone:

Do you have allergies to the following? Please answer Y / N 

Antibiotics*
No
Yes
Soaps*
No
Yes
Metals*
No
Yes
Latex*
No
Yes
Alcohol*
No
Yes
Cosmetics*
No
Yes

Do you currently have or have you ever had any communicable disease(s) or infections? Please answer Y / N

Hepatitis*
No
Yes
Herpes*
No
Yes
Gonorrhea*
No
Yes
HIV*
No
Yes
Syphilis*
No
Yes
Staph*
No
Yes
Tuberculosis*
No
Yes

Other:
Are you currently taking any medication?*
No
Yes

If yes, what?

Please answer the following in regards to your medical history: Please answer Y / N 

Heart Condition*
No
Yes
Pregnant*
No
Yes
Skin Condition*
No
Yes
Epileptic*
No
Yes
Diabetic*
No
Yes
Fainting/Dizziness*
No
Yes
Subject to Rashes*
No
Yes
High Blood Pressure*
No
Yes
IV Drugs*
No
Yes

Other:

COVID-19 Screening Questions - Please answer Y / N for each question: 

In the last 2 weeks have you: 

Been tested for COVID-19?*
No
Yes
Had flu-like symptoms such as a fever, chills, nausea, vomiting, diarrhea, shortness of breath, sore throat, muscle aches, or loss of taste or smell?*
No
Yes
Been in contact with anyone who has tested positive for COVID-19 or has flu-like symptoms?*
No
Yes
Traveled outside of the United States or traveled on a cruise ship?*
No
Yes
Client'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(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

Age:

Occupation:

Type of Design:
Artist's Name:*

If Guest Artist, please list their name:

Location on Body:
First Time:*
No
Yes

*Please note the following information will not be disclosed. It is for the safety of you and your artist


Physicians Name:

Phone:

Do you have allergies to the following? Please answer Y / N 

Antibiotics*
No
Yes
Soaps*
No
Yes
Metals*
No
Yes
Latex*
No
Yes
Alcohol*
No
Yes
Cosmetics*
No
Yes

Do you currently have or have you ever had any communicable disease(s) or infections? Please answer Y / N

Hepatitis*
No
Yes
Herpes*
No
Yes
Gonorrhea*
No
Yes
HIV*
No
Yes
Syphilis*
No
Yes
Staph*
No
Yes
Tuberculosis*
No
Yes

Other:
Are you currently taking any medication?*
No
Yes

If yes, what?

Please answer the following in regards to your medical history: Please answer Y / N 

Heart Condition*
No
Yes
Pregnant*
No
Yes
Skin Condition*
No
Yes
Epileptic*
No
Yes
Diabetic*
No
Yes
Fainting/Dizziness*
No
Yes
Subject to Rashes*
No
Yes
High Blood Pressure*
No
Yes
IV Drugs*
No
Yes

Other:

COVID-19 Screening Questions - Please answer Y / N for each question: 

In the last 2 weeks have you: 

Been tested for COVID-19?*
No
Yes
Had flu-like symptoms such as a fever, chills, nausea, vomiting, diarrhea, shortness of breath, sore throat, muscle aches, or loss of taste or smell?*
No
Yes
Been in contact with anyone who has tested positive for COVID-19 or has flu-like symptoms?*
No
Yes
Traveled outside of the United States or traveled on a cruise ship?*
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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