Please complete, sign and submit each below:

1. Client Info and Medical History.

2. Tattoo Consent and Liability Waiver

1. Client Information and Medical History

First name

Last name

Phone

Birthday

Month

Day

Year

Address

Do you have, or have you ever had the following:

Hepatitis B

Yes

Hepatitis C

Yes

HIV/AIDS

Yes

Diabetes

Yes

History of hemophilia or any other blood disorder/disease?

Yes

Skin diseases or skin lesions?

Yes

Sensitivities to soaps, disinfectants, etc?

Yes

History of allergies or adverse reactions to pigments, dyes, latex, etc?

Yes

Scarring (keloids)?

Yes

Tuberculosis?

Yes

Immune disorders?

Yes

History of epilepsy, seizures, fainting, or narcolepsy?

Yes

History of heart murmur or any heart disease/condition?

Yes

History of taking medications such as anticoagulants that thin the blood and/or interfere with blood clotting?

Yes

Are you now under the influence of alcohol or drugs?

Yes

Are there any other medical conditions which may affect your body art healing process?

Yes

FEMALES: Are you pregnant or breast feeding/nursing?

Yes

If you answered "Yes" to any of the above conditions, it is recommended that you consult with your personal care physician before any tattooing procedures are performed.

Requested Artist:

Short Description of Design and Body Sites/Locations

Written aftercare instructions received?

Yes

Signature

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Tattoo Consent and Liability Waiver:

Please read and check the boxes provided for each field to verify you understand each provision. Feel free to ask any questions regarding this waiver.

In consideration of receiving a tattoo from Oakleigh Apothecary LLC, including its

artists, associates, apprentices, agents, or any employees (hereinafter referred to as the

“Tattoo Studio” I agree to the following:

I have been fully informed of the inherent risks associated with getting a tattoo. Therefore, I fully understand that these risks, known and unknown, can lead to injury including but not limited to: infection, scarring, difficulties in the detection of melanoma and allergic reactions to tattoo pigment, latex gloves and/or soap.

Having been informed of the potential risks associated with getting a tattoo I wish to proceed with the tattoo procedure and application and freely accept and expressly assume any and all risks that may arise from tattooing.

I WAIVE AND RELEASE to the fullest extent permitted by law any person of the Tattoo Studio from all liability whatsoever, including but not limited to, any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise from the procedure and application of my tattoo, whether caused by the negligence or fault of either the Tattoo Studio, or otherwise.

The Tattoo Studio has given me the full opportunity to ask any question about the procedure and application of my tattoo and all of my questions, if any, have been answered to my total satisfaction.

The Tattoo Studio has given me instructions on the care of my tattoo while it's healing. I understand and will follow them. I acknowledge that it is possible that the tattoo can become infected, particularly if I do not follow the instructions given to me. If any touch-up work to the tattoo is needed due to my own negligence, I agree that the work will be done at my own expense.

I am not under the influence of alcohol or drugs, and I am voluntarily submitting to be tattooed by the Tattoo Studio without duress or coercion.

I do not suffer from diabetes, epilepsy, hemophilia, heart condition(s), nor do I take blood thinning medication. I do not have any other medical or skin condition that may interfere with the procedure, application or healing of the tattoo. I am not the recipient of an organ or bone marrow transplant or, if I am, I have taken the prescribed preventative regimen of antibiotics that is required by my doctor in advance of any invasive procedure such as tattooing or piercing.

I am not pregnant or nursing. I do not have a mental impairment that may affect my judgement in getting the tattoo.

The Tattoo Studio is not responsible for the meaning or spelling of the symbol or text that I have provide to them or chosen from the flash (design) sheets.

Variations in color and design may exist between the tattoo art I have selected and the actual tattoo when it is applied to my body. I also understand that over time, the colors and the clarity of my tattoo will fade due to unprotected exposure to the sun and the naturally occurring dispersion of pigment under the skin.

A tattoo is a permanent change to my appearance and can only be removed by laser or surgical means, which can be disfiguring and/or costly and which in all likelihood will not result in the restoration of my skin to its exact appearance before being tattooed.

I release the right to any photographs taken of me and the tattoo and give consent in advance to their reproduction in print or electronic form. (For assurance, if you do not initial this provision, please inform the Tattoo Studio NOT to take any pictures of you and your completed tattoo).

I agree that the Tattoo Studio has a NO REFUND policy on tattoos, piercing and/or retail sales and I will not ask for a refund for any reason whatsoever.

I agree to reimburse the Tattoo Studio for any attorneys' fees and costs incurred in any legal action I bring against the Tattoo Studio and in which either the Artist of the Tattoo Studio is the prevailing party. I agree that the courts of located in the County of Mobile within the State of Alabama shall have jurisdiction and venue over me and shall have exclusive jurisdiction for the purposes of litigating any dispute arising out of or related to this agreement.

I acknowledge that I have been given adequate opportunity to read and understand this document that it was not presented to me at the last minute and grasp that I am signing a legal contract waiving certain rights to recover damages against the Tattoo Studio.

If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document. I hereby declare that I am of legal age (and have provided valid proof of age and identification) and am competent to sign this Agreement.

I HAVE READ THE AGREEMENT, I UNDERSTAND IT, AND I AGREE TO BE BOUND BY IT.

*Please Upload a Pic of your License. (Take the pic first, then upload from your photo album, loading direct from your camera will not work.)

Required

Signature

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Please complete, sign and submit each below:

1. Client Information and Medical History

Tattoo Consent and Liability Waiver:

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