The Electric Crayon
Tattoo Company LLC.
13692#B E. ILIFF AVE
AURORA CO 80014
303-745-7245
BODY ART CONSENT AND RELEASE
-That I, ______(clearly PRINT your name) have been fully informed of the inherent risks, associated with getting a tattoo and/or piercing. I fully understand that these risks, known and unknown can lead to injury, including but not limited to infection, scarring and keloiding, allergic reactions to jewelry, latex gloves, and/or soap. Having been informed of the potential risks associated with getting a tattoo and/or piercing, I still wish to proceed with the tattoo and/or piercing and I freely accept and expressly assume any and all risks that may arise from the procedure.
-I agree to waive and release to the fullest extent permitted by law each of the Artists and The Electric CrayonTattoo Co. from all liability whatsoever, for 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 tattoo and/or piercing, whether caused by the negligence or fault of either the Artist or The Electric CrayonTattoo Co., or otherwise.
-That both the Artist and The Electric CrayonTattoo Co. have given me the full opportunity to ask any, and all questions about the tattoo and/or piercing procedure and the staff has answered these questions to my total satisfaction and I understand tattoos are a permanent body change.
-I affirm that both the Artist and The Electric CrayonTattoo Co. have given me instructions on the care of my tattoo and/or piercing while it’s healing, and I understand them and will follow them. I acknowledge that it is possible that the tattoo and/or piercing can become infected, particularly if I do not follow the instructions given to me.
-I release all rights to any photographs taken of me and the tattoo and/or piercing and give consent in advance to their reproduction in print or electronic form.
-I understand that I have denied the use of the barriers provided by the tattoo shop. I also understand that the tattoo shop is under security surveillance and I still relinquish my right to privacy barriers. If you would like to use barriers, please ask your artist.
-Please initial here showing you agree to the above______
I represent and warrant to The Electric Crayon Tattoo Co.that the following is true and correct. (PLEASE PRINT)
NAME: ______AGE: ______DATE OF BIRTH: ______
STREET ADDRESS: ______
CITY: ______STATE: ______ZIP: ______
PHONE: ______I.D./DRIVER'S LICENSE #: ______STATE OF ISSUE: ______
Do you have a history of any of the following? Y/N
Communicable Disease ____Diabetes ____Hemophilia____Heart Condition ____Narcolepsy ____
Skin Disease/Lesions ____Epilepsy ____Seizures ____Fainting ____Whining ____
Are you currently? Y/N
Pregnant or Nursing ____Under the influence of drugs or alcohol ____
Treatment with anticoagulants or other medications that thin the blood and/or interfere with blood clotting) ____
Any known allergies to: Y/N
Pigments of dyes ____Metals ____Disinfectants ____ Soaps ____Latex Gloves ____
BODY LOCATION/VARIETY OF TATTOO/PIERCING: ______ARTIST: ______PRICE: ______
PARENT/GUARDIANS: If under the age of 18, parent or guardian agrees with any and all above conditions and statements and by signing below gives consent for the minor to receive body art work at the Electric Crayon as well as releases any photograph that may be taken of that work to be published without compensation.
Name:______Age:______DOB:______I.D./D.L.#:______State of issue:______
Street Address: ____________City: ______State: _____
CLIENT SIGNATURE: ______TODAY'S DATE: ______
PARENT/GUARDIAN SIGNATURE: ______TODAY'S DATE: ______
HOW DID YOU HEAR ABOUT US? ______
!!!EMPLOYEES ONLY!!!
TATTOO NEEDLE LOT #______NEEDLE EXPERATION DATE______TUBE AUTOCLAVE DATE______TUBE LOT NUMBER______
INK COLOR______INK LOT NUMBER______
TATTOO AND/OR PIERCINGNEEDLE LOT #______NEEDLE EXPERATION DATE______JEWELRY SIZE______JEWELRY AUTOCLAVE DATE______
JEWELRY LOT #______CLAMP AUTOCLAVE DATE______CLAMP LOT #______