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X-Treme Ink Tattoo
22 East Market Street
West Chester, Pa

Consent to application of TATTOO and release and waiver of all claims.

I acknowledge by signing this document that I have been given the full opportunity to ask any and all questions that I might have about obtaining a tattoo from X-Treme Ink Tattoo. Also, I acknowledge that all of my questions were answered to my full and total satisfaction. I specifically acknowledge that I have been advised of the facts and matters set forth below and agree as follows.

Please INITIAL all that apply:

Date: July 25, 2021 

I am eighteen (18) years of age or older. No tattoo will be given to a minor for ANY reason, including parental consent.

 

I am not pregnant. If you are, we cannot tattoo you. PERIOD! 

 

I am free from all communicable diseases ( Hepatitis A, B, C, HIV, AIDS, etc.). If you are not, please inform your artist. 

 

I understand that a tattoo is a permanent change to my appearance. 

 

I understand that there is a possibility of an allergic reaction to the dyes, pigments, processes, and equipment used to apply the tattoo. 

 

I understand that there is a risk of infection and compliance with our aftercare instructions is absolutely imperative to prevent this. 

 

No representations were made to me as to the ability to later change, alter, or remove my tattoo. 

 

The obtaining of this tattoo is by my choice alone and I consent to the application and to any actions or conduct the associates, agents, or representatives of X-Treme Ink Tattoo feel are necessary to perform the tattoo. 

 

I agree to release and forever discharge and hold harmless X-Treme Ink Tattoo and its associates, agents, representatives, and shareholders from any and all claims, damages, or legal actions arising from or connected in any way with my obtaining of the tattoo or the procedures and consent used to apply my tattoo. 

 

Credit/Debit/Gift cards have a convenience charge. Ask your artist. 

 

 

***Relax and sit still during the tattoo. Moving can negatively affect the tattoo process.***

***No phone calls, face time, or live videos while being tattooed***

First Participant's Name

First Name*

Middle Name

Last Name*

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

Please list medications, allergies, and medical conditions that may impact the tattoo process.
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

Please list medications, allergies, and medical conditions that may impact the tattoo process.
Third Participant's Name

First Name*

Middle Name

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

Please list medications, allergies, and medical conditions that may impact the tattoo process.
Fourth Participant's Name

First Name*

Middle Name

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

Please list medications, allergies, and medical conditions that may impact the tattoo process.
Fifth Participant's Name

First Name*

Middle Name

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

Please list medications, allergies, and medical conditions that may impact the tattoo process.
Sixth Participant's Name

First Name*

Middle Name

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

Please list medications, allergies, and medical conditions that may impact the tattoo process.
Seventh Participant's Name

First Name*

Middle Name

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

Please list medications, allergies, and medical conditions that may impact the tattoo process.
Eighth Participant's Name

First Name*

Middle Name

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

Please list medications, allergies, and medical conditions that may impact the tattoo process.
Ninth Participant's Name

First Name*

Middle Name

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

Please list medications, allergies, and medical conditions that may impact the tattoo process.
Tenth Participant's Name

First Name*

Middle Name

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

Please list medications, allergies, and medical conditions that may impact the tattoo process.
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*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Please list medications, allergies, and medical conditions that may impact the tattoo process.
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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