Client Information *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Procedure Consent *

I hereby consent to the application of permanent tattooing by the above-named artist at the listed studio. I understand the nature of the tattoo process and that I am receiving a permanent mark on my skin made by inserting pigments through the epidermis and into the dermal layer using needles.

I consent.

Emergency Contact *

Please provide the name and contact details of someone we can reach in case of a medical emergency or unexpected situation during your appointment. This person should be readily available by phone and ideally located nearby. This information will only be used for safety purposes and kept confidential.

First Name

Last Name

Phone

(###)

###

####

HEALTH & MEDICAL HISTORY *

Please check any that apply to you:

Blood clotting disorders (e.g. hemophilia)

Heart condition / pacemaker

Bloodborne diseases (HIV, Hepatitis B/C)

Diabetes (Type I / Type II)

Epilepsy or seizures

Immune system disorders or immunosuppressive therapy

Skin conditions (eczema, psoriasis, keloids, etc.)

Current infections (including cold/flu, staph, etc.)

History of fainting or dizziness

History of allergic reactions to tattoo pigments, iodine, latex, or topical anesthetics

Use of blood thinners or anticoagulants

Use of Accutane or other retinoids (in past 12 months)

Pregnancy or nursing

Cancer / recent chemotherapy or radiation

None of these apply to me

Do you have any allergies (medication, latex, metals, shellfish, etc.)? *

Yes (please list below)

No

ACKNOWLEDGEMENT OF RISKS *

I understand and acknowledge the following: ☑ Tattooing involves breaking the skin and may cause discomfort, bleeding, bruising, or scabbing. ☑ Infection, scarring, allergic reactions, or ink rejection may occur despite proper aftercare. ☑ I have been advised of proper aftercare procedures and accept full responsibility for aftercare. ☑ My tattoo may fade over time due to sun exposure, skin type, ink color, or placement. ☑ No guarantee has been made regarding the final appearance or longevity of the tattoo. ☑ I may not be eligible for touch-ups due to improper aftercare or lifestyle factors. ☑ Tattoos are permanent. Laser removal or cover-up may be costly and/or ineffective. ☑ Photographs of my tattoo may be taken and used for marketing unless I request otherwise. ☑ I may be refused service for health, hygiene, intoxication, or disrespectful behavior.

I understand and acknowledge.

Third-Party Liability Release *

By signing this waiver, I acknowledge and agree that Thun LLC, including its owners, affiliates, and the owners of the building where Heart Space Tattoo LLC operates, shall not be held liable for any injury, infection, allergic reaction, dissatisfaction, or other damages, whether to person or property, that may arise in connection with the tattoo services I receive at Heart Space Tattoo LLC. I understand that Thun LLC and the building owners are not involved in the provision, supervision, or performance of any tattoo services, and do not endorse or assume responsibility for the actions or practices of Heart Space Tattoo LLC. Accordingly, I hereby release and hold harmless Thun LLC and the property owner from any and all claims, demands, or liabilities associated with my visit, treatment, or services rendered.

I confirm and agree.

Type full name as signature: *

First Name

Last Name

By checking this box, I formally agree that typing my name constitutes a legal signature *

I Agree