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Chameleon Tattoo and Body Piercing

33 UNION SQUARE

SOMERVILLE MA

02143

(617) 876 0412

Waiver of Liability Relating of Coronavirus/COVID-19

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, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.

Chameleon Tattoo and Body Piercing have put in place preventative measures to reduce the spread of COVID-19; however, Chameleon Tattoo and Body Piercing cannot guarantee that you will not become infected with COVID-19. Further, getting a tattoo or piercing could increase your risk of contracting COVID-19.

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by entering Chameleon Tattoo and Body Piercing and that such exposure of infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 may result from the actions, omissions, or negligence of myself and others, including , but not limited to, Chameleon Tattoo and Body Piercing employees.

I voluntarily agree to assume all of the possible risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my attendance at Chameleon Tattoo and Body Piercing.

I hereby release, discharge, and hold harmless Chameleon Tattoo and Body Piercing LLC, its employees, agents, of and from the Claims, including all liabilities, claims, actions, damages, costs, or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of Chameleon Tattoo and Body Piercing employees, agents, whether a COVID-19 infection occurs before, during, or after participation in any tattoo, piercing work, or any other services provided by Chameleon Tattoo and Body Piercing LLC.

I Agree


ALL TATTOO CLIENTS MUST SIGN AND RECIEVE A COPY OF THIS FORM, PRIOR TO ANY TATTOO PROCEDURE

TATTOO DISCLOUSRE STATEMENT AND CONSENT FORM

As with any invasive procedure, tattooing may involve possible health risks.

These risks may include:

  • pain, bleeding, swelling;
  • scarring, hypertrophic scarring, and keloid formation;
  • possible adverse or allergic reaction to ink/dye pigment;
  • decreased ability of physician to locate skin melanoma in tattoo area;
  • possible nerve damage;
  • febrile (fever) illness;
  • tetanus; and
  • infection - local or systemic
  • The use of unsterile equipment and needles can spread infectious disease; it is extremely important to be sure that all equipment is clean and sanitary before use.
  • The inks, or dyes, used for tattoos are color additives. Currently no color additives have been approved by the FDA for tattoos.
  • Tattoos should be considered permanent. Removal of a tattoo may require surgery or other medical procedures which in some cases may result in scarring or additional scarring of the skin. Tattoos may cause permanent discoloration. Inks/dyes/pigments may change color over time. Think carefully before getting tattooed.
  • Blood donations cannot be made for one year after getting a tattoo.

The Tattoo Practitioner should:

  • Properly and thoroughly cleanse the area before the tattooing procedure
  • Use sterilized equipment
  • Use sterile techniques
  • Provide information on the aftercare of the area receiving a tattoo, available at https://www.chameleonbodyarts.com/tattoo-after-care

HEALTH HISTORY

The following conditions may increase health risks associated with receiving a tattoo:

  • diabetes;
  • hemophilia (bleeding);
  • skin diseases, lesions, or skin sensitivities to soaps, disinfectants etc.;
  • history of allergies or adverse reactions to pigments, dyes, or other sensitivities;
  • history of epilepsy, seizures, fainting or narcolepsy;
  • use of medications such as anticoagulants, (such as coumadin) which thin the blood and/or interfere with blood clotting; and
  • hepatitis or HIV infection

I have read and understand the above information

I Agree

I do not have a condition that prevents me from receiving a tattoo

I Agree

I am not under the influence of any drug or alcohol

I Agree

I am not pregnant and don't suspect that I may be pregnant

I Agree

I consent to the performace of the tattooing procedure and I have been given verbal and written aftercare instructions as required by the Cambridge Body Art Regulation

I Agree

I am aware that all information disclosed will be kept confidential

I Agree

I am aware that a copy of this document will be provided to me

I Agree

Consult a health care provider for:

  • unexpected redness, tenderness or swelling at the site of the tattoo
  • rash
  • unexpected drainage at or from the site of the tattoo
  • fever within 24 hours of the tattoo

PROCEDURE FOR FILING A COMPLAINT

If there is any sign of injury, infection, complication or disease as a result of a tattoo procedure, first contact a healthcare provider for medical evaluation. Then notify this establishment and the CAMBRIDGE PUBLIC HEALTH DEPARTMENT, 119 WINDSOR STREET, CAMBRIDGE,MA 02139. Phone: (617) 665-3848

Today's date: December 26, 2024

First Client Name

First Name*

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First Client Information
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Fourth Client Information
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Parent or Guardian's Email Address

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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.


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

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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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