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Silver Sparrow Tattoos

1090 NE Federal Highway Stuart, Florida 34994

Medical Disclosure and Release Form

I hereby release and discharge Silver Sparrow Tattoos 

and its employees from any type of negligence, liability,

claim, action, demand, and compensation in law and in

equity, which I have or might have, now and hereafter;

by reason of my request to be tattooed. I also

specifically release and forever discharge Silver Sparrow Tattoos

 and its employees and its agents, for any

and all loss or damage on account of injury to my

person or property caused by Silver Sparrow Tattoos,

otherwise; by reason of my request to be tattooed. I

give permission to copyright and/or publish

photographs of myself with or without my name in any

such manner as deemed proper to their use. I realize

that misrepresentation or falsification of information

provided by me is a crime and is subject to prosecution.

I further certify that I am over the age of eighteen and

am not intoxicated or under the influence of any

narcotic substance and made this statement entirely of

free will and sound mind. I acknowledge that a tattoo is

a permanent change to my appearance and that no

representations have been made to me as to the ability

to later change or remove my tattoo. I acknowledge it is

not reasonably possible for the representatives and

employees of Silver Sparrow Tattoos 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 a reaction is possible. I acknowledge that

infection is always possible as a result of the obtaining

of a tattoo, particularly in the event that I do not take

proper care of my tattoo. I also acknowledge that I have

received aftercare instructions for my tattoo today. This

is a legal binding contract.

February 28, 2024


First Client’s Name

First Name*

Last Name*

Phone*
First Client’s Date of Birth*
First Client’s Information

Age: *

Occupation: *

Description of Tattoo: *

Location on body: *

If guest artist, please list their name:
Artist’s Name:*

First time getting tattooed? *

* Please note, the following information will not be disclosed. It is for the safety of you and your artist.



Physician’s name: *

Physician’s phone: *

Do you have allergies to any of the following? Please answer Y/N


Antibiotics*
No
Yes
Soaps*
No
Yes
Metals*
No
Yes
Latex*
No
Yes
Alcohol**
No
Yes
Cosmetics*
No
Yes
Adhesives*
No
Yes

Do you currently have or have ever had any communicable disease(s) or infections? Please answer Y/N


Hepatitis*
No
Yes
Herpes*
No
Yes
Gohnorrhea*
No
Yes
HIV/AIDS*
No
Yes
Syphilis*
No
Yes
Staph*
No
Yes
Tuberculosis *
No
Yes

Other:
Are you currently taking any medication(s)?*
No
Yes

If yes, please list medications:

Please answer the following in regards to your medical history. Please answer Y/N


Heart Condition*
No
Yes
Currently Pregnant *
No
Yes
Skin Condition*
No
Yes
Epileptic *
No
Yes
Diabetic*
No
Yes
Fainting/dizziness*
No
Yes
Subject to Rashes*
No
Yes
High Blood Pressure*
No
Yes
IV Drugs*
No
Yes

Other:

COVID-19 Screening Questions - Please Answer Y/N

In the last two weeks, have you


Had flu-like symptoms such as fever, chills, nausea, vomiting, diarrhea, shortness of breath, sore throat, muscle aches, or loss of taste or smell?*
No
Yes
Been tested for COVID-19?*
No
Yes
Been in contact with someone who has tested positive for COVID-19 or has flu like symptoms?*
No
Yes
Traveled outside of the United States or traveled on a cruise ship?*
No
Yes
First Client’s Signature*
Second Client’s Name

First Name*

Last Name*

Phone*
Second Client’s Date of Birth*
Second Client’s Information

Age: *

Occupation: *

Description of Tattoo: *

Location on body: *

If guest artist, please list their name:
Artist’s Name:*

First time getting tattooed? *

* Please note, the following information will not be disclosed. It is for the safety of you and your artist.



Physician’s name: *

Physician’s phone: *

Do you have allergies to any of the following? Please answer Y/N


Antibiotics*
No
Yes
Soaps*
No
Yes
Metals*
No
Yes
Latex*
No
Yes
Alcohol**
No
Yes
Cosmetics*
No
Yes
Adhesives*
No
Yes

Do you currently have or have ever had any communicable disease(s) or infections? Please answer Y/N


Hepatitis*
No
Yes
Herpes*
No
Yes
Gohnorrhea*
No
Yes
HIV/AIDS*
No
Yes
Syphilis*
No
Yes
Staph*
No
Yes
Tuberculosis *
No
Yes

Other:
Are you currently taking any medication(s)?*
No
Yes

If yes, please list medications:

Please answer the following in regards to your medical history. Please answer Y/N


Heart Condition*
No
Yes
Currently Pregnant *
No
Yes
Skin Condition*
No
Yes
Epileptic *
No
Yes
Diabetic*
No
Yes
Fainting/dizziness*
No
Yes
Subject to Rashes*
No
Yes
High Blood Pressure*
No
Yes
IV Drugs*
No
Yes

Other:

COVID-19 Screening Questions - Please Answer Y/N

In the last two weeks, have you


Had flu-like symptoms such as fever, chills, nausea, vomiting, diarrhea, shortness of breath, sore throat, muscle aches, or loss of taste or smell?*
No
Yes
Been tested for COVID-19?*
No
Yes
Been in contact with someone who has tested positive for COVID-19 or has flu like symptoms?*
No
Yes
Traveled outside of the United States or traveled on a cruise ship?*
No
Yes
Third Client’s Name

First Name*

Last Name*

Phone*
Third Client’s Date of Birth*
Third Client’s Information

Age: *

Occupation: *

Description of Tattoo: *

Location on body: *

If guest artist, please list their name:
Artist’s Name:*

First time getting tattooed? *

* Please note, the following information will not be disclosed. It is for the safety of you and your artist.



Physician’s name: *

Physician’s phone: *

Do you have allergies to any of the following? Please answer Y/N


Antibiotics*
No
Yes
Soaps*
No
Yes
Metals*
No
Yes
Latex*
No
Yes
Alcohol**
No
Yes
Cosmetics*
No
Yes
Adhesives*
No
Yes

Do you currently have or have ever had any communicable disease(s) or infections? Please answer Y/N


Hepatitis*
No
Yes
Herpes*
No
Yes
Gohnorrhea*
No
Yes
HIV/AIDS*
No
Yes
Syphilis*
No
Yes
Staph*
No
Yes
Tuberculosis *
No
Yes

Other:
Are you currently taking any medication(s)?*
No
Yes

If yes, please list medications:

Please answer the following in regards to your medical history. Please answer Y/N


Heart Condition*
No
Yes
Currently Pregnant *
No
Yes
Skin Condition*
No
Yes
Epileptic *
No
Yes
Diabetic*
No
Yes
Fainting/dizziness*
No
Yes
Subject to Rashes*
No
Yes
High Blood Pressure*
No
Yes
IV Drugs*
No
Yes

Other:

COVID-19 Screening Questions - Please Answer Y/N

In the last two weeks, have you


Had flu-like symptoms such as fever, chills, nausea, vomiting, diarrhea, shortness of breath, sore throat, muscle aches, or loss of taste or smell?*
No
Yes
Been tested for COVID-19?*
No
Yes
Been in contact with someone who has tested positive for COVID-19 or has flu like symptoms?*
No
Yes
Traveled outside of the United States or traveled on a cruise ship?*
No
Yes
Fourth Client’s Name

First Name*

Last Name*

Phone*
Fourth Client’s Date of Birth*
Fourth Client’s Information

Age: *

Occupation: *

Description of Tattoo: *

Location on body: *

If guest artist, please list their name:
Artist’s Name:*

First time getting tattooed? *

* Please note, the following information will not be disclosed. It is for the safety of you and your artist.



Physician’s name: *

Physician’s phone: *

Do you have allergies to any of the following? Please answer Y/N


Antibiotics*
No
Yes
Soaps*
No
Yes
Metals*
No
Yes
Latex*
No
Yes
Alcohol**
No
Yes
Cosmetics*
No
Yes
Adhesives*
No
Yes

Do you currently have or have ever had any communicable disease(s) or infections? Please answer Y/N


Hepatitis*
No
Yes
Herpes*
No
Yes
Gohnorrhea*
No
Yes
HIV/AIDS*
No
Yes
Syphilis*
No
Yes
Staph*
No
Yes
Tuberculosis *
No
Yes

Other:
Are you currently taking any medication(s)?*
No
Yes

If yes, please list medications:

Please answer the following in regards to your medical history. Please answer Y/N


Heart Condition*
No
Yes
Currently Pregnant *
No
Yes
Skin Condition*
No
Yes
Epileptic *
No
Yes
Diabetic*
No
Yes
Fainting/dizziness*
No
Yes
Subject to Rashes*
No
Yes
High Blood Pressure*
No
Yes
IV Drugs*
No
Yes

Other:

COVID-19 Screening Questions - Please Answer Y/N

In the last two weeks, have you


Had flu-like symptoms such as fever, chills, nausea, vomiting, diarrhea, shortness of breath, sore throat, muscle aches, or loss of taste or smell?*
No
Yes
Been tested for COVID-19?*
No
Yes
Been in contact with someone who has tested positive for COVID-19 or has flu like symptoms?*
No
Yes
Traveled outside of the United States or traveled on a cruise ship?*
No
Yes
Fifth Client’s Name

First Name*

Last Name*

Phone*
Fifth Client’s Date of Birth*
Fifth Client’s Information

Age: *

Occupation: *

Description of Tattoo: *

Location on body: *

If guest artist, please list their name:
Artist’s Name:*

First time getting tattooed? *

* Please note, the following information will not be disclosed. It is for the safety of you and your artist.



Physician’s name: *

Physician’s phone: *

Do you have allergies to any of the following? Please answer Y/N


Antibiotics*
No
Yes
Soaps*
No
Yes
Metals*
No
Yes
Latex*
No
Yes
Alcohol**
No
Yes
Cosmetics*
No
Yes
Adhesives*
No
Yes

Do you currently have or have ever had any communicable disease(s) or infections? Please answer Y/N


Hepatitis*
No
Yes
Herpes*
No
Yes
Gohnorrhea*
No
Yes
HIV/AIDS*
No
Yes
Syphilis*
No
Yes
Staph*
No
Yes
Tuberculosis *
No
Yes

Other:
Are you currently taking any medication(s)?*
No
Yes

If yes, please list medications:

Please answer the following in regards to your medical history. Please answer Y/N


Heart Condition*
No
Yes
Currently Pregnant *
No
Yes
Skin Condition*
No
Yes
Epileptic *
No
Yes
Diabetic*
No
Yes
Fainting/dizziness*
No
Yes
Subject to Rashes*
No
Yes
High Blood Pressure*
No
Yes
IV Drugs*
No
Yes

Other:

COVID-19 Screening Questions - Please Answer Y/N

In the last two weeks, have you


Had flu-like symptoms such as fever, chills, nausea, vomiting, diarrhea, shortness of breath, sore throat, muscle aches, or loss of taste or smell?*
No
Yes
Been tested for COVID-19?*
No
Yes
Been in contact with someone who has tested positive for COVID-19 or has flu like symptoms?*
No
Yes
Traveled outside of the United States or traveled on a cruise ship?*
No
Yes
Sixth Client’s Name

First Name*

Last Name*

Phone*
Sixth Client’s Date of Birth*
Sixth Client’s Information

Age: *

Occupation: *

Description of Tattoo: *

Location on body: *

If guest artist, please list their name:
Artist’s Name:*

First time getting tattooed? *

* Please note, the following information will not be disclosed. It is for the safety of you and your artist.



Physician’s name: *

Physician’s phone: *

Do you have allergies to any of the following? Please answer Y/N


Antibiotics*
No
Yes
Soaps*
No
Yes
Metals*
No
Yes
Latex*
No
Yes
Alcohol**
No
Yes
Cosmetics*
No
Yes
Adhesives*
No
Yes

Do you currently have or have ever had any communicable disease(s) or infections? Please answer Y/N


Hepatitis*
No
Yes
Herpes*
No
Yes
Gohnorrhea*
No
Yes
HIV/AIDS*
No
Yes
Syphilis*
No
Yes
Staph*
No
Yes
Tuberculosis *
No
Yes

Other:
Are you currently taking any medication(s)?*
No
Yes

If yes, please list medications:

Please answer the following in regards to your medical history. Please answer Y/N


Heart Condition*
No
Yes
Currently Pregnant *
No
Yes
Skin Condition*
No
Yes
Epileptic *
No
Yes
Diabetic*
No
Yes
Fainting/dizziness*
No
Yes
Subject to Rashes*
No
Yes
High Blood Pressure*
No
Yes
IV Drugs*
No
Yes

Other:

COVID-19 Screening Questions - Please Answer Y/N

In the last two weeks, have you


Had flu-like symptoms such as fever, chills, nausea, vomiting, diarrhea, shortness of breath, sore throat, muscle aches, or loss of taste or smell?*
No
Yes
Been tested for COVID-19?*
No
Yes
Been in contact with someone who has tested positive for COVID-19 or has flu like symptoms?*
No
Yes
Traveled outside of the United States or traveled on a cruise ship?*
No
Yes
Seventh Client’s Name

First Name*

Last Name*

Phone*
Seventh Client’s Date of Birth*
Seventh Client’s Information

Age: *

Occupation: *

Description of Tattoo: *

Location on body: *

If guest artist, please list their name:
Artist’s Name:*

First time getting tattooed? *

* Please note, the following information will not be disclosed. It is for the safety of you and your artist.



Physician’s name: *

Physician’s phone: *

Do you have allergies to any of the following? Please answer Y/N


Antibiotics*
No
Yes
Soaps*
No
Yes
Metals*
No
Yes
Latex*
No
Yes
Alcohol**
No
Yes
Cosmetics*
No
Yes
Adhesives*
No
Yes

Do you currently have or have ever had any communicable disease(s) or infections? Please answer Y/N


Hepatitis*
No
Yes
Herpes*
No
Yes
Gohnorrhea*
No
Yes
HIV/AIDS*
No
Yes
Syphilis*
No
Yes
Staph*
No
Yes
Tuberculosis *
No
Yes

Other:
Are you currently taking any medication(s)?*
No
Yes

If yes, please list medications:

Please answer the following in regards to your medical history. Please answer Y/N


Heart Condition*
No
Yes
Currently Pregnant *
No
Yes
Skin Condition*
No
Yes
Epileptic *
No
Yes
Diabetic*
No
Yes
Fainting/dizziness*
No
Yes
Subject to Rashes*
No
Yes
High Blood Pressure*
No
Yes
IV Drugs*
No
Yes

Other:

COVID-19 Screening Questions - Please Answer Y/N

In the last two weeks, have you


Had flu-like symptoms such as fever, chills, nausea, vomiting, diarrhea, shortness of breath, sore throat, muscle aches, or loss of taste or smell?*
No
Yes
Been tested for COVID-19?*
No
Yes
Been in contact with someone who has tested positive for COVID-19 or has flu like symptoms?*
No
Yes
Traveled outside of the United States or traveled on a cruise ship?*
No
Yes
Eighth Client’s Name

First Name*

Last Name*

Phone*
Eighth Client’s Date of Birth*
Eighth Client’s Information

Age: *

Occupation: *

Description of Tattoo: *

Location on body: *

If guest artist, please list their name:
Artist’s Name:*

First time getting tattooed? *

* Please note, the following information will not be disclosed. It is for the safety of you and your artist.



Physician’s name: *

Physician’s phone: *

Do you have allergies to any of the following? Please answer Y/N


Antibiotics*
No
Yes
Soaps*
No
Yes
Metals*
No
Yes
Latex*
No
Yes
Alcohol**
No
Yes
Cosmetics*
No
Yes
Adhesives*
No
Yes

Do you currently have or have ever had any communicable disease(s) or infections? Please answer Y/N


Hepatitis*
No
Yes
Herpes*
No
Yes
Gohnorrhea*
No
Yes
HIV/AIDS*
No
Yes
Syphilis*
No
Yes
Staph*
No
Yes
Tuberculosis *
No
Yes

Other:
Are you currently taking any medication(s)?*
No
Yes

If yes, please list medications:

Please answer the following in regards to your medical history. Please answer Y/N


Heart Condition*
No
Yes
Currently Pregnant *
No
Yes
Skin Condition*
No
Yes
Epileptic *
No
Yes
Diabetic*
No
Yes
Fainting/dizziness*
No
Yes
Subject to Rashes*
No
Yes
High Blood Pressure*
No
Yes
IV Drugs*
No
Yes

Other:

COVID-19 Screening Questions - Please Answer Y/N

In the last two weeks, have you


Had flu-like symptoms such as fever, chills, nausea, vomiting, diarrhea, shortness of breath, sore throat, muscle aches, or loss of taste or smell?*
No
Yes
Been tested for COVID-19?*
No
Yes
Been in contact with someone who has tested positive for COVID-19 or has flu like symptoms?*
No
Yes
Traveled outside of the United States or traveled on a cruise ship?*
No
Yes
Ninth Client’s Name

First Name*

Last Name*

Phone*
Ninth Client’s Date of Birth*
Ninth Client’s Information

Age: *

Occupation: *

Description of Tattoo: *

Location on body: *

If guest artist, please list their name:
Artist’s Name:*

First time getting tattooed? *

* Please note, the following information will not be disclosed. It is for the safety of you and your artist.



Physician’s name: *

Physician’s phone: *

Do you have allergies to any of the following? Please answer Y/N


Antibiotics*
No
Yes
Soaps*
No
Yes
Metals*
No
Yes
Latex*
No
Yes
Alcohol**
No
Yes
Cosmetics*
No
Yes
Adhesives*
No
Yes

Do you currently have or have ever had any communicable disease(s) or infections? Please answer Y/N


Hepatitis*
No
Yes
Herpes*
No
Yes
Gohnorrhea*
No
Yes
HIV/AIDS*
No
Yes
Syphilis*
No
Yes
Staph*
No
Yes
Tuberculosis *
No
Yes

Other:
Are you currently taking any medication(s)?*
No
Yes

If yes, please list medications:

Please answer the following in regards to your medical history. Please answer Y/N


Heart Condition*
No
Yes
Currently Pregnant *
No
Yes
Skin Condition*
No
Yes
Epileptic *
No
Yes
Diabetic*
No
Yes
Fainting/dizziness*
No
Yes
Subject to Rashes*
No
Yes
High Blood Pressure*
No
Yes
IV Drugs*
No
Yes

Other:

COVID-19 Screening Questions - Please Answer Y/N

In the last two weeks, have you


Had flu-like symptoms such as fever, chills, nausea, vomiting, diarrhea, shortness of breath, sore throat, muscle aches, or loss of taste or smell?*
No
Yes
Been tested for COVID-19?*
No
Yes
Been in contact with someone who has tested positive for COVID-19 or has flu like symptoms?*
No
Yes
Traveled outside of the United States or traveled on a cruise ship?*
No
Yes
Tenth Client’s Name

First Name*

Last Name*

Phone*
Tenth Client’s Date of Birth*
Tenth Client’s Information

Age: *

Occupation: *

Description of Tattoo: *

Location on body: *

If guest artist, please list their name:
Artist’s Name:*

First time getting tattooed? *

* Please note, the following information will not be disclosed. It is for the safety of you and your artist.



Physician’s name: *

Physician’s phone: *

Do you have allergies to any of the following? Please answer Y/N


Antibiotics*
No
Yes
Soaps*
No
Yes
Metals*
No
Yes
Latex*
No
Yes
Alcohol**
No
Yes
Cosmetics*
No
Yes
Adhesives*
No
Yes

Do you currently have or have ever had any communicable disease(s) or infections? Please answer Y/N


Hepatitis*
No
Yes
Herpes*
No
Yes
Gohnorrhea*
No
Yes
HIV/AIDS*
No
Yes
Syphilis*
No
Yes
Staph*
No
Yes
Tuberculosis *
No
Yes

Other:
Are you currently taking any medication(s)?*
No
Yes

If yes, please list medications:

Please answer the following in regards to your medical history. Please answer Y/N


Heart Condition*
No
Yes
Currently Pregnant *
No
Yes
Skin Condition*
No
Yes
Epileptic *
No
Yes
Diabetic*
No
Yes
Fainting/dizziness*
No
Yes
Subject to Rashes*
No
Yes
High Blood Pressure*
No
Yes
IV Drugs*
No
Yes

Other:

COVID-19 Screening Questions - Please Answer Y/N

In the last two weeks, have you


Had flu-like symptoms such as fever, chills, nausea, vomiting, diarrhea, shortness of breath, sore throat, muscle aches, or loss of taste or smell?*
No
Yes
Been tested for COVID-19?*
No
Yes
Been in contact with someone who has tested positive for COVID-19 or has flu like symptoms?*
No
Yes
Traveled outside of the United States or traveled on a cruise ship?*
No
Yes
Parent or Guardian's Email Address

Email*

Confirm Email*
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

First Name*

Last Name*

Emergency Contact's Phone Number*
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*

Last Name*

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

Age: *

Occupation: *

Description of Tattoo: *

Location on body: *

If guest artist, please list their name:
Artist’s Name:*

First time getting tattooed? *

* Please note, the following information will not be disclosed. It is for the safety of you and your artist.



Physician’s name: *

Physician’s phone: *

Do you have allergies to any of the following? Please answer Y/N


Antibiotics*
No
Yes
Soaps*
No
Yes
Metals*
No
Yes
Latex*
No
Yes
Alcohol**
No
Yes
Cosmetics*
No
Yes
Adhesives*
No
Yes

Do you currently have or have ever had any communicable disease(s) or infections? Please answer Y/N


Hepatitis*
No
Yes
Herpes*
No
Yes
Gohnorrhea*
No
Yes
HIV/AIDS*
No
Yes
Syphilis*
No
Yes
Staph*
No
Yes
Tuberculosis *
No
Yes

Other:
Are you currently taking any medication(s)?*
No
Yes

If yes, please list medications:

Please answer the following in regards to your medical history. Please answer Y/N


Heart Condition*
No
Yes
Currently Pregnant *
No
Yes
Skin Condition*
No
Yes
Epileptic *
No
Yes
Diabetic*
No
Yes
Fainting/dizziness*
No
Yes
Subject to Rashes*
No
Yes
High Blood Pressure*
No
Yes
IV Drugs*
No
Yes

Other:

COVID-19 Screening Questions - Please Answer Y/N

In the last two weeks, have you


Had flu-like symptoms such as fever, chills, nausea, vomiting, diarrhea, shortness of breath, sore throat, muscle aches, or loss of taste or smell?*
No
Yes
Been tested for COVID-19?*
No
Yes
Been in contact with someone who has tested positive for COVID-19 or has flu like symptoms?*
No
Yes
Traveled outside of the United States or traveled on a cruise ship?*
No
Yes
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. 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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