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STIGMA INK

STANDARD RELEASE FORM

I am at least 18 years old, or I am accompanied by my mother, father, or legal guardian.

I Agree

I don’t have a heart condition. I don’t have epilepsy. I haven’t had hepatitis for the past year. I am not a hemophiliac. 

I Agree

I do not have HIV+ or have AIDS, Hepatitis or Syphilis if so I will alert an employee of (Stigma Ink) before any work takes place. 

I Agree

I am not under the influence of drugs or alcohol. 

I Agree

I am not pregnant or nursing. 

I Agree

I have eaten in the past 4 hours. 

I Agree

To my knowledge I don’t have any physical, mental, or medical impairment or disability which might affect my wellbeing as a direct or indirect result of my decision to have tattoo- related work or a body piercing done at this time. 

I Agree

I agree not to sue (Stigma Ink) in connection with all damages, claims, demands, rights and causes of ac=on of whatever kind of nature, based upon injuries or property damage to, or death of myself or any other persons arising from my decision to have tattoo-related work or body piercing done at this =me, whether caused by any negligence of (Stigma Ink). 

I Agree

I acknowledge that I have been given aftercare instructions and I agree to follow all instructions concerning the care of my tattoo and/or body 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 Agree

Being of sound mind and body, I hereby release all persons representing (Stigma Ink) of (Tampa, Fl) from all responsibility, I accept all responsibility myself for any consequences that might stem from my decision to have tattoo-related work, or a body piercing done by (Stigma Ink). 

I Agree

I have been told and I am aware of the risks of getting a body piercing and/or tattoo. These risks include but are not limited to scar, bruising, swelling, disfigurement, rejection, allergic reactions, irritation, and pain. 

I Agree

I understand that tattoos on the hands, feet and lips are NOT guaranteed, and the tattoo may fade or fall out completely. 

I Agree

I understand that I am getting a body art procedure done in a safe, clean environment using sterile equipment. B

I Agree

I understand that there are variables that (Stigma Ink) cannot control while your body art is healing. It is my responsibility to keep my body art clean and follow all aftercare instructions. 

I Agree

I understand that tattoos and / or body piercings are NOT guaranteed to heal, however (Stigma Ink) will to the best of their ability to help me to troubleshoot any problems that may occur during and after the healing process. This troubleshooting or advice does not take place of the diagnosis of a medical professional. 

I Agree

I have been given verbal and written aftercare instructions and I understand them. 

I Agree

I acknowledge that I have read and understand this form and all information stated is true and correct. 

Date: June 20, 2024

First Client's Name

First Name*

Middle Name

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information
Do you have a history of bleeding disorders?*
No
Yes
Do you have now or ever contracted Hepatitis A, B, or C or Syphilis or HIV+?*
No
Yes
Do you have any allergies including latex, metals, soaps, creams, medicines, etc.?*
No
Yes

Age:

Sex:

How did you hear about us?

PHYSICAN INFO: Use our recommendation or add your own physician below 

(Advent Health Centra Care)
(301 N Dale Mabry Hwy)
Tampa Fl 813- 284-0985


Physician Info:

Price of Piercing / Tattoo:
First Client's Signature*
Second Client's Name

First Name*

Middle Name

Last Name*
Second Client's Date of Birth*
Second Client's Information
Do you have a history of bleeding disorders?*
No
Yes
Do you have now or ever contracted Hepatitis A, B, or C or Syphilis or HIV+?*
No
Yes
Do you have any allergies including latex, metals, soaps, creams, medicines, etc.?*
No
Yes

Age:

Sex:

How did you hear about us?

PHYSICAN INFO: Use our recommendation or add your own physician below 

(Advent Health Centra Care)
(301 N Dale Mabry Hwy)
Tampa Fl 813- 284-0985


Physician Info:

Price of Piercing / Tattoo:
Second Client's Signature*
Third Client's Name

First Name*

Middle Name

Last Name*
Third Client's Date of Birth*
Third Client's Information
Do you have a history of bleeding disorders?*
No
Yes
Do you have now or ever contracted Hepatitis A, B, or C or Syphilis or HIV+?*
No
Yes
Do you have any allergies including latex, metals, soaps, creams, medicines, etc.?*
No
Yes

Age:

Sex:

How did you hear about us?

PHYSICAN INFO: Use our recommendation or add your own physician below 

(Advent Health Centra Care)
(301 N Dale Mabry Hwy)
Tampa Fl 813- 284-0985


Physician Info:

Price of Piercing / Tattoo:
Third Client's Signature*
Fourth Client's Name

First Name*

Middle Name

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information
Do you have a history of bleeding disorders?*
No
Yes
Do you have now or ever contracted Hepatitis A, B, or C or Syphilis or HIV+?*
No
Yes
Do you have any allergies including latex, metals, soaps, creams, medicines, etc.?*
No
Yes

Age:

Sex:

How did you hear about us?

PHYSICAN INFO: Use our recommendation or add your own physician below 

(Advent Health Centra Care)
(301 N Dale Mabry Hwy)
Tampa Fl 813- 284-0985


Physician Info:

Price of Piercing / Tattoo:
Fourth Client's Signature*
Fifth Client's Name

First Name*

Middle Name

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information
Do you have a history of bleeding disorders?*
No
Yes
Do you have now or ever contracted Hepatitis A, B, or C or Syphilis or HIV+?*
No
Yes
Do you have any allergies including latex, metals, soaps, creams, medicines, etc.?*
No
Yes

Age:

Sex:

How did you hear about us?

PHYSICAN INFO: Use our recommendation or add your own physician below 

(Advent Health Centra Care)
(301 N Dale Mabry Hwy)
Tampa Fl 813- 284-0985


Physician Info:

Price of Piercing / Tattoo:
Fifth Client's Signature*
Sixth Client's Name

First Name*

Middle Name

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information
Do you have a history of bleeding disorders?*
No
Yes
Do you have now or ever contracted Hepatitis A, B, or C or Syphilis or HIV+?*
No
Yes
Do you have any allergies including latex, metals, soaps, creams, medicines, etc.?*
No
Yes

Age:

Sex:

How did you hear about us?

PHYSICAN INFO: Use our recommendation or add your own physician below 

(Advent Health Centra Care)
(301 N Dale Mabry Hwy)
Tampa Fl 813- 284-0985


Physician Info:

Price of Piercing / Tattoo:
Sixth Client's Signature*
Seventh Client's Name

First Name*

Middle Name

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information
Do you have a history of bleeding disorders?*
No
Yes
Do you have now or ever contracted Hepatitis A, B, or C or Syphilis or HIV+?*
No
Yes
Do you have any allergies including latex, metals, soaps, creams, medicines, etc.?*
No
Yes

Age:

Sex:

How did you hear about us?

PHYSICAN INFO: Use our recommendation or add your own physician below 

(Advent Health Centra Care)
(301 N Dale Mabry Hwy)
Tampa Fl 813- 284-0985


Physician Info:

Price of Piercing / Tattoo:
Seventh Client's Signature*
Eighth Client's Name

First Name*

Middle Name

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information
Do you have a history of bleeding disorders?*
No
Yes
Do you have now or ever contracted Hepatitis A, B, or C or Syphilis or HIV+?*
No
Yes
Do you have any allergies including latex, metals, soaps, creams, medicines, etc.?*
No
Yes

Age:

Sex:

How did you hear about us?

PHYSICAN INFO: Use our recommendation or add your own physician below 

(Advent Health Centra Care)
(301 N Dale Mabry Hwy)
Tampa Fl 813- 284-0985


Physician Info:

Price of Piercing / Tattoo:
Eighth Client's Signature*
Ninth Client's Name

First Name*

Middle Name

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information
Do you have a history of bleeding disorders?*
No
Yes
Do you have now or ever contracted Hepatitis A, B, or C or Syphilis or HIV+?*
No
Yes
Do you have any allergies including latex, metals, soaps, creams, medicines, etc.?*
No
Yes

Age:

Sex:

How did you hear about us?

PHYSICAN INFO: Use our recommendation or add your own physician below 

(Advent Health Centra Care)
(301 N Dale Mabry Hwy)
Tampa Fl 813- 284-0985


Physician Info:

Price of Piercing / Tattoo:
Ninth Client's Signature*
Tenth Client's Name

First Name*

Middle Name

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information
Do you have a history of bleeding disorders?*
No
Yes
Do you have now or ever contracted Hepatitis A, B, or C or Syphilis or HIV+?*
No
Yes
Do you have any allergies including latex, metals, soaps, creams, medicines, etc.?*
No
Yes

Age:

Sex:

How did you hear about us?

PHYSICAN INFO: Use our recommendation or add your own physician below 

(Advent Health Centra Care)
(301 N Dale Mabry Hwy)
Tampa Fl 813- 284-0985


Physician Info:

Price of Piercing / Tattoo:
Tenth Client's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Photo Of ID
  
Please upload a photo of your Driver's License *
Valid file types: JPG, GIF, PNG, and PDF
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:*
Emergency contact information (Do NOT write 911):

Name: *

Relationship: *

Phone: *

Address: *
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*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Do you have a history of bleeding disorders?*
No
Yes
Do you have now or ever contracted Hepatitis A, B, or C or Syphilis or HIV+?*
No
Yes
Do you have any allergies including latex, metals, soaps, creams, medicines, etc.?*
No
Yes

Age:

Sex:

How did you hear about us?

PHYSICAN INFO: Use our recommendation or add your own physician below 

(Advent Health Centra Care)
(301 N Dale Mabry Hwy)
Tampa Fl 813- 284-0985


Physician Info:

Price of Piercing / Tattoo:
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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