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Disclosure Statement

As with any invasive procedure, tattooing may involve possible health risks. These risks may include pain, bleeding, swelling, infection, scarring, and/or nerve damage.

Non-sterile equipment and needles can spread infectious disease; it is extremely important that all equipment is clean, sterile and/or single use. The area to be tattooed will be properly cleansed before the procedure; sterile, clean and single use equipment and universal precautions will be used. Proper written aftercare information will be provided after the procedure, as well as verbally explained. 

The following conditions may increase health risks associated with getting a tattoo, and at the artist's discretion, may require a doctors note to preform the tattoo;

Diabetes, Hemophila, Skin Disease, Lesions, Skin Sensitivities to Soaps or Disinfectants, History of Allergies or Adverse Reactions to Pigments or Dyes, History of Epilepsy, Seizures, Fainting, or Narcolepsy, Use of Anticoagulants / Blood Thinners, Hepatitis, or HIV / AIDS.

  • 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 reaction is possible.
  • I realize that vacations in color and design may exist between any tattoo as selected by me, and as ultimately applied to my body. I understand that if my skin color/tone is dark, the colors may not appear as bright as they do on lighter color/ toned skin. 
  • I understand if I have any skin treatments, laser hair removal, plastic surgery, or any other skin altering procedures, it may result in adverse changes to my tattoo. 
  • I understand that I am permitted from donating blood for one full year after the completion of my tattoo. 

Waiver of Lawsuit / Liability

I have carefully read and fully understand all provisions of this release. I hereby forever release and waive my right to bring to suit against Seth Campbell / Crown of Thorns Tattoo and its owners, officers, directors, managers, officials, trustees, agents, employees, or other representatives in connection with exposure and infection related to utilizing Seth Campbell / Crown of Thorns Tattoo's services and premises. I understand that this waiver means I give up my right to bring any claims including personal injuries, death, disease or property losses, or any other loss, including but not limited to claims of negligence and give up any claim I may have to seek damages, whether known or unknown, foreseen or unforeseen. 

Choice of Law

I understand and agree that the law of the State of Massachusetts will apply to this contract. 

I acknowledge that I am over the age of 18 and I have truthfully represented that the obtaining of a tattoo is my choice alone. I do not have a condition that prevents me from getting a tattoo. I consent to the application of the tattoo and to any actions or conduct of the representatives and employees of the tattoo shop necessary to preform the tattoo procedure. I also understand that Seth Campbell / Crown of Thorns Tattoo has the right to refuse service to any clients at any time, for any reason, if felt a risk is involved. 

I Agree


First Client Name

First Name*

Middle Name

Last Name*

Phone*
First Client Date of Birth*
First Client Information
Do you have any allergies to anything that may be used in the tattoo procedure? Check any / all that apply; *
Latex
Soaps
Metals
Alcohol
Petroleum
Lidocaine
Lanolin Oil
Cosmetics
Adhesives
None
Do you have any of the following? Please check all that may apply; *
Hepatitis
Tuberculosis
Gonorrhea
Syphilis
HIV / AIDS
Herpes
Staph
None
Do you have a history of any of the following? Check all that may apply; *
Heart Disease
High Blood Pressure
Hemophilia
Psoriasis
Eczema
Epilepsy
Seizures
Narcolepsy
Fainting
Diabetes
None
Are you pregnant or currently breastfeeding?*
Yes
No
Do you have an auto-immunity disease?*
Yes
No

If yes, please list:
Do you have asthma?*
Yes
No
Do you currently have any infections?*
Yes
No

If yes, please list:
Are you prone to fainting?*
Yes
No
Are you prone to scarring and/or keloiding?*
Yes
No
Do you currently have any kind of skin disease, rash, sunburning on the area to be tattooed?*
Yes
No
Are you currently taking any medication, prescription or non-prescription?*
Yes
No

If yes, please list:
First Client Signature*
Second Client Name

First Name*

Middle Name

Last Name*
Second Client Date of Birth*
Second Client Information
Do you have any allergies to anything that may be used in the tattoo procedure? Check any / all that apply; *
Latex
Soaps
Metals
Alcohol
Petroleum
Lidocaine
Lanolin Oil
Cosmetics
Adhesives
None
Do you have any of the following? Please check all that may apply; *
Hepatitis
Tuberculosis
Gonorrhea
Syphilis
HIV / AIDS
Herpes
Staph
None
Do you have a history of any of the following? Check all that may apply; *
Heart Disease
High Blood Pressure
Hemophilia
Psoriasis
Eczema
Epilepsy
Seizures
Narcolepsy
Fainting
Diabetes
None
Are you pregnant or currently breastfeeding?*
Yes
No
Do you have an auto-immunity disease?*
Yes
No

If yes, please list:
Do you have asthma?*
Yes
No
Do you currently have any infections?*
Yes
No

If yes, please list:
Are you prone to fainting?*
Yes
No
Are you prone to scarring and/or keloiding?*
Yes
No
Do you currently have any kind of skin disease, rash, sunburning on the area to be tattooed?*
Yes
No
Are you currently taking any medication, prescription or non-prescription?*
Yes
No

If yes, please list:
Third Client Name

First Name*

Middle Name

Last Name*
Third Client Date of Birth*
Third Client Information
Do you have any allergies to anything that may be used in the tattoo procedure? Check any / all that apply; *
Latex
Soaps
Metals
Alcohol
Petroleum
Lidocaine
Lanolin Oil
Cosmetics
Adhesives
None
Do you have any of the following? Please check all that may apply; *
Hepatitis
Tuberculosis
Gonorrhea
Syphilis
HIV / AIDS
Herpes
Staph
None
Do you have a history of any of the following? Check all that may apply; *
Heart Disease
High Blood Pressure
Hemophilia
Psoriasis
Eczema
Epilepsy
Seizures
Narcolepsy
Fainting
Diabetes
None
Are you pregnant or currently breastfeeding?*
Yes
No
Do you have an auto-immunity disease?*
Yes
No

If yes, please list:
Do you have asthma?*
Yes
No
Do you currently have any infections?*
Yes
No

If yes, please list:
Are you prone to fainting?*
Yes
No
Are you prone to scarring and/or keloiding?*
Yes
No
Do you currently have any kind of skin disease, rash, sunburning on the area to be tattooed?*
Yes
No
Are you currently taking any medication, prescription or non-prescription?*
Yes
No

If yes, please list:
Fourth Client Name

First Name*

Middle Name

Last Name*
Fourth Client Date of Birth*
Fourth Client Information
Do you have any allergies to anything that may be used in the tattoo procedure? Check any / all that apply; *
Latex
Soaps
Metals
Alcohol
Petroleum
Lidocaine
Lanolin Oil
Cosmetics
Adhesives
None
Do you have any of the following? Please check all that may apply; *
Hepatitis
Tuberculosis
Gonorrhea
Syphilis
HIV / AIDS
Herpes
Staph
None
Do you have a history of any of the following? Check all that may apply; *
Heart Disease
High Blood Pressure
Hemophilia
Psoriasis
Eczema
Epilepsy
Seizures
Narcolepsy
Fainting
Diabetes
None
Are you pregnant or currently breastfeeding?*
Yes
No
Do you have an auto-immunity disease?*
Yes
No

If yes, please list:
Do you have asthma?*
Yes
No
Do you currently have any infections?*
Yes
No

If yes, please list:
Are you prone to fainting?*
Yes
No
Are you prone to scarring and/or keloiding?*
Yes
No
Do you currently have any kind of skin disease, rash, sunburning on the area to be tattooed?*
Yes
No
Are you currently taking any medication, prescription or non-prescription?*
Yes
No

If yes, please list:
Fifth Client Name

First Name*

Middle Name

Last Name*
Fifth Client Date of Birth*
Fifth Client Information
Do you have any allergies to anything that may be used in the tattoo procedure? Check any / all that apply; *
Latex
Soaps
Metals
Alcohol
Petroleum
Lidocaine
Lanolin Oil
Cosmetics
Adhesives
None
Do you have any of the following? Please check all that may apply; *
Hepatitis
Tuberculosis
Gonorrhea
Syphilis
HIV / AIDS
Herpes
Staph
None
Do you have a history of any of the following? Check all that may apply; *
Heart Disease
High Blood Pressure
Hemophilia
Psoriasis
Eczema
Epilepsy
Seizures
Narcolepsy
Fainting
Diabetes
None
Are you pregnant or currently breastfeeding?*
Yes
No
Do you have an auto-immunity disease?*
Yes
No

If yes, please list:
Do you have asthma?*
Yes
No
Do you currently have any infections?*
Yes
No

If yes, please list:
Are you prone to fainting?*
Yes
No
Are you prone to scarring and/or keloiding?*
Yes
No
Do you currently have any kind of skin disease, rash, sunburning on the area to be tattooed?*
Yes
No
Are you currently taking any medication, prescription or non-prescription?*
Yes
No

If yes, please list:
Sixth Client Name

First Name*

Middle Name

Last Name*
Sixth Client Date of Birth*
Sixth Client Information
Do you have any allergies to anything that may be used in the tattoo procedure? Check any / all that apply; *
Latex
Soaps
Metals
Alcohol
Petroleum
Lidocaine
Lanolin Oil
Cosmetics
Adhesives
None
Do you have any of the following? Please check all that may apply; *
Hepatitis
Tuberculosis
Gonorrhea
Syphilis
HIV / AIDS
Herpes
Staph
None
Do you have a history of any of the following? Check all that may apply; *
Heart Disease
High Blood Pressure
Hemophilia
Psoriasis
Eczema
Epilepsy
Seizures
Narcolepsy
Fainting
Diabetes
None
Are you pregnant or currently breastfeeding?*
Yes
No
Do you have an auto-immunity disease?*
Yes
No

If yes, please list:
Do you have asthma?*
Yes
No
Do you currently have any infections?*
Yes
No

If yes, please list:
Are you prone to fainting?*
Yes
No
Are you prone to scarring and/or keloiding?*
Yes
No
Do you currently have any kind of skin disease, rash, sunburning on the area to be tattooed?*
Yes
No
Are you currently taking any medication, prescription or non-prescription?*
Yes
No

If yes, please list:
Seventh Client Name

First Name*

Middle Name

Last Name*
Seventh Client Date of Birth*
Seventh Client Information
Do you have any allergies to anything that may be used in the tattoo procedure? Check any / all that apply; *
Latex
Soaps
Metals
Alcohol
Petroleum
Lidocaine
Lanolin Oil
Cosmetics
Adhesives
None
Do you have any of the following? Please check all that may apply; *
Hepatitis
Tuberculosis
Gonorrhea
Syphilis
HIV / AIDS
Herpes
Staph
None
Do you have a history of any of the following? Check all that may apply; *
Heart Disease
High Blood Pressure
Hemophilia
Psoriasis
Eczema
Epilepsy
Seizures
Narcolepsy
Fainting
Diabetes
None
Are you pregnant or currently breastfeeding?*
Yes
No
Do you have an auto-immunity disease?*
Yes
No

If yes, please list:
Do you have asthma?*
Yes
No
Do you currently have any infections?*
Yes
No

If yes, please list:
Are you prone to fainting?*
Yes
No
Are you prone to scarring and/or keloiding?*
Yes
No
Do you currently have any kind of skin disease, rash, sunburning on the area to be tattooed?*
Yes
No
Are you currently taking any medication, prescription or non-prescription?*
Yes
No

If yes, please list:
Eighth Client Name

First Name*

Middle Name

Last Name*
Eighth Client Date of Birth*
Eighth Client Information
Do you have any allergies to anything that may be used in the tattoo procedure? Check any / all that apply; *
Latex
Soaps
Metals
Alcohol
Petroleum
Lidocaine
Lanolin Oil
Cosmetics
Adhesives
None
Do you have any of the following? Please check all that may apply; *
Hepatitis
Tuberculosis
Gonorrhea
Syphilis
HIV / AIDS
Herpes
Staph
None
Do you have a history of any of the following? Check all that may apply; *
Heart Disease
High Blood Pressure
Hemophilia
Psoriasis
Eczema
Epilepsy
Seizures
Narcolepsy
Fainting
Diabetes
None
Are you pregnant or currently breastfeeding?*
Yes
No
Do you have an auto-immunity disease?*
Yes
No

If yes, please list:
Do you have asthma?*
Yes
No
Do you currently have any infections?*
Yes
No

If yes, please list:
Are you prone to fainting?*
Yes
No
Are you prone to scarring and/or keloiding?*
Yes
No
Do you currently have any kind of skin disease, rash, sunburning on the area to be tattooed?*
Yes
No
Are you currently taking any medication, prescription or non-prescription?*
Yes
No

If yes, please list:
Ninth Client Name

First Name*

Middle Name

Last Name*
Ninth Client Date of Birth*
Ninth Client Information
Do you have any allergies to anything that may be used in the tattoo procedure? Check any / all that apply; *
Latex
Soaps
Metals
Alcohol
Petroleum
Lidocaine
Lanolin Oil
Cosmetics
Adhesives
None
Do you have any of the following? Please check all that may apply; *
Hepatitis
Tuberculosis
Gonorrhea
Syphilis
HIV / AIDS
Herpes
Staph
None
Do you have a history of any of the following? Check all that may apply; *
Heart Disease
High Blood Pressure
Hemophilia
Psoriasis
Eczema
Epilepsy
Seizures
Narcolepsy
Fainting
Diabetes
None
Are you pregnant or currently breastfeeding?*
Yes
No
Do you have an auto-immunity disease?*
Yes
No

If yes, please list:
Do you have asthma?*
Yes
No
Do you currently have any infections?*
Yes
No

If yes, please list:
Are you prone to fainting?*
Yes
No
Are you prone to scarring and/or keloiding?*
Yes
No
Do you currently have any kind of skin disease, rash, sunburning on the area to be tattooed?*
Yes
No
Are you currently taking any medication, prescription or non-prescription?*
Yes
No

If yes, please list:
Tenth Client Name

First Name*

Middle Name

Last Name*
Tenth Client Date of Birth*
Tenth Client Information
Do you have any allergies to anything that may be used in the tattoo procedure? Check any / all that apply; *
Latex
Soaps
Metals
Alcohol
Petroleum
Lidocaine
Lanolin Oil
Cosmetics
Adhesives
None
Do you have any of the following? Please check all that may apply; *
Hepatitis
Tuberculosis
Gonorrhea
Syphilis
HIV / AIDS
Herpes
Staph
None
Do you have a history of any of the following? Check all that may apply; *
Heart Disease
High Blood Pressure
Hemophilia
Psoriasis
Eczema
Epilepsy
Seizures
Narcolepsy
Fainting
Diabetes
None
Are you pregnant or currently breastfeeding?*
Yes
No
Do you have an auto-immunity disease?*
Yes
No

If yes, please list:
Do you have asthma?*
Yes
No
Do you currently have any infections?*
Yes
No

If yes, please list:
Are you prone to fainting?*
Yes
No
Are you prone to scarring and/or keloiding?*
Yes
No
Do you currently have any kind of skin disease, rash, sunburning on the area to be tattooed?*
Yes
No
Are you currently taking any medication, prescription or non-prescription?*
Yes
No

If yes, please list:
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
Client Identification
  
Please upload photo of your state issued Drivers License, ID, or Passport *
Valid file types: JPG, GIF, PNG, and PDF
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*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Do you have any allergies to anything that may be used in the tattoo procedure? Check any / all that apply; *
Latex
Soaps
Metals
Alcohol
Petroleum
Lidocaine
Lanolin Oil
Cosmetics
Adhesives
None
Do you have any of the following? Please check all that may apply; *
Hepatitis
Tuberculosis
Gonorrhea
Syphilis
HIV / AIDS
Herpes
Staph
None
Do you have a history of any of the following? Check all that may apply; *
Heart Disease
High Blood Pressure
Hemophilia
Psoriasis
Eczema
Epilepsy
Seizures
Narcolepsy
Fainting
Diabetes
None
Are you pregnant or currently breastfeeding?*
Yes
No
Do you have an auto-immunity disease?*
Yes
No

If yes, please list:
Do you have asthma?*
Yes
No
Do you currently have any infections?*
Yes
No

If yes, please list:
Are you prone to fainting?*
Yes
No
Are you prone to scarring and/or keloiding?*
Yes
No
Do you currently have any kind of skin disease, rash, sunburning on the area to be tattooed?*
Yes
No
Are you currently taking any medication, prescription or non-prescription?*
Yes
No

If yes, please list:
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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