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Tattoo / Piercing Release Form

ORIANA TATTOO

 

I am at least 18 years of age. I do not have a heart condition. I am not pregnant. I am not under the influence of drugs or alcohol. To my knowledge I do not have any physical, mental, or medical impairment or disability, including allergies to any ink, which may affect my well-being as a direct or indirect result of my decision to have any tattoo or piercing work done. I agree to follow all instructions concerning the care of my tattoo or piercing while it is healing. I agree that any touch up work needed due to my own negligence will be done at my own expense. I understand that if my skin is dark or tanned, the colors of the tattoo will not appear as bright as they do on light skin. I understand that the tattoo or piercing may possible cause my body to scar. Being off sound mind, and body, I hereby release any and all persons representing ORIANA TATTOO STUDIOS from all responsibility. I accept any and all responsibility myself for any consequences from my decision to have any tattoo or piercing related work done by anyone representing the business known as ORIANA TATTOO STUDIOS in connection with any and all damages, claims, demands, rights, and causes of action whatever nature, based on injuries, person, or property damage to, or death of myself or any other persons arising from the decision to have a tattoo or piercing work done. Whether or not caused by any negligence of anyone representing ORIANA TATTOO STUDIOS. I agree myself, heirs. Assigns, and legal representatives to hold ORIANA TATTOO STUDIOS harmless from all damages, causes of action, claims, judgment, cost of litigation, attorney fees, and all other cost and expenses which might arise from my decision to have any tattoo or piercing related work done by anyone representing ORIANA TATTOO STUDIOS. I give ORIANA TATTOO STUDIOS and its representative’s full permission to take photographs or videos of me and to use those photographs as they see fit with no compensation to myself. I agree to leave the premises of ORIANA TATTOO STUDIOS promptly upon request. For any reason whatsoever, by any agent or employee of ORIANA TATTOO STUDIOS. I agree these waivers also pertain to and are designed to protect any and all establishment where ORIANA TATTOO STUDIOS may conduct business now and in the future. I represent and warrant that the above and following is true and correct. Non-Refundable policy:  All payments for Tattoos and piercing Services under all Order Forms are non-refundable.

 

 

 

First customers Name

First Name*

Middle Name

Last Name*

Phone*
First customers Date of Birth*
First customers Piercing
Piercing Placement *

Physician Name:

Physician Address:

Physician Telephone Number:

Race

Customer age

Emergency Contact Name:

Emergency Contact Address:

Emergency Contact Telephone Number:

List any allergies you have, including allergies to medications, and allergies to any topical solutions used by this body piercing establishment:

Do you have a history of bleeding disorders?

Today's Date *
First customers Signature*
Second customers Name

First Name*

Middle Name

Last Name*

Phone*
Second customers Date of Birth*
Second customers Piercing
Piercing Placement *

Physician Name:

Physician Address:

Physician Telephone Number:

Race

Customer age

Emergency Contact Name:

Emergency Contact Address:

Emergency Contact Telephone Number:

List any allergies you have, including allergies to medications, and allergies to any topical solutions used by this body piercing establishment:

Do you have a history of bleeding disorders?

Today's Date *
Third customers Name

First Name*

Middle Name

Last Name*

Phone*
Third customers Date of Birth*
Third customers Piercing
Piercing Placement *

Physician Name:

Physician Address:

Physician Telephone Number:

Race

Customer age

Emergency Contact Name:

Emergency Contact Address:

Emergency Contact Telephone Number:

List any allergies you have, including allergies to medications, and allergies to any topical solutions used by this body piercing establishment:

Do you have a history of bleeding disorders?

Today's Date *
Fourth customers Name

First Name*

Middle Name

Last Name*

Phone*
Fourth customers Date of Birth*
Fourth customers Piercing
Piercing Placement *

Physician Name:

Physician Address:

Physician Telephone Number:

Race

Customer age

Emergency Contact Name:

Emergency Contact Address:

Emergency Contact Telephone Number:

List any allergies you have, including allergies to medications, and allergies to any topical solutions used by this body piercing establishment:

Do you have a history of bleeding disorders?

Today's Date *
Fifth customers Name

First Name*

Middle Name

Last Name*

Phone*
Fifth customers Date of Birth*
Fifth customers Piercing
Piercing Placement *

Physician Name:

Physician Address:

Physician Telephone Number:

Race

Customer age

Emergency Contact Name:

Emergency Contact Address:

Emergency Contact Telephone Number:

List any allergies you have, including allergies to medications, and allergies to any topical solutions used by this body piercing establishment:

Do you have a history of bleeding disorders?

Today's Date *
Sixth customers Name

First Name*

Middle Name

Last Name*

Phone*
Sixth customers Date of Birth*
Sixth customers Piercing
Piercing Placement *

Physician Name:

Physician Address:

Physician Telephone Number:

Race

Customer age

Emergency Contact Name:

Emergency Contact Address:

Emergency Contact Telephone Number:

List any allergies you have, including allergies to medications, and allergies to any topical solutions used by this body piercing establishment:

Do you have a history of bleeding disorders?

Today's Date *
Seventh customers Name

First Name*

Middle Name

Last Name*

Phone*
Seventh customers Date of Birth*
Seventh customers Piercing
Piercing Placement *

Physician Name:

Physician Address:

Physician Telephone Number:

Race

Customer age

Emergency Contact Name:

Emergency Contact Address:

Emergency Contact Telephone Number:

List any allergies you have, including allergies to medications, and allergies to any topical solutions used by this body piercing establishment:

Do you have a history of bleeding disorders?

Today's Date *
Eighth customers Name

First Name*

Middle Name

Last Name*

Phone*
Eighth customers Date of Birth*
Eighth customers Piercing
Piercing Placement *

Physician Name:

Physician Address:

Physician Telephone Number:

Race

Customer age

Emergency Contact Name:

Emergency Contact Address:

Emergency Contact Telephone Number:

List any allergies you have, including allergies to medications, and allergies to any topical solutions used by this body piercing establishment:

Do you have a history of bleeding disorders?

Today's Date *
Ninth customers Name

First Name*

Middle Name

Last Name*

Phone*
Ninth customers Date of Birth*
Ninth customers Piercing
Piercing Placement *

Physician Name:

Physician Address:

Physician Telephone Number:

Race

Customer age

Emergency Contact Name:

Emergency Contact Address:

Emergency Contact Telephone Number:

List any allergies you have, including allergies to medications, and allergies to any topical solutions used by this body piercing establishment:

Do you have a history of bleeding disorders?

Today's Date *
Tenth customers Name

First Name*

Middle Name

Last Name*

Phone*
Tenth customers Date of Birth*
Tenth customers Piercing
Piercing Placement *

Physician Name:

Physician Address:

Physician Telephone Number:

Race

Customer age

Emergency Contact Name:

Emergency Contact Address:

Emergency Contact Telephone Number:

List any allergies you have, including allergies to medications, and allergies to any topical solutions used by this body piercing establishment:

Do you have a history of bleeding disorders?

Today's Date *
customers 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 Name Email Address

Email*
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
To Be Completed By The Artist

DATE *
Tattoo / Piercing*
Tattoo
Piercing
Academy

Artist Name *

Artist's signature
PRICE:

$ *
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 Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Name Date of Birth*
Parent or Guardian's Name Piercing
Piercing Placement *

Physician Name:

Physician Address:

Physician Telephone Number:

Race

Customer age

Emergency Contact Name:

Emergency Contact Address:

Emergency Contact Telephone Number:

List any allergies you have, including allergies to medications, and allergies to any topical solutions used by this body piercing establishment:

Do you have a history of bleeding disorders?

Today's Date *
Parent or Guardian's Name 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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