By signing this form I agree to the following:
I agree to follow all verbal and/or written instructions concerning the care of my tattoo. Any touch-up
work that needs
to be done due to my own negligence will be at my own expense. This includes using things like numbing
cream. If my skin
is dark, it will affect the intensity and color of the tattoo. I do not have Any mental, physical, or
medical impairment
which may affect my judgment or my well-being as a direct or indirect result of my Decision to have tattoo
work performed
at this time. Keepsake Custome Tattoo Inc. and it's artists, contractors, and employees should not be held
responsible for
any claims, damages, actions, judgments, litigation costs, attorney’s fees, and all other cost expenses
which might arise
from my decision to have a tattoo work done at this time.
By signing this form, I hereby certify that, to the best of my knowledge, the information I have provided
is correct. I certify
that I am at least 18 years of age and will provide legal identification to be photocopied and attached to
this form. I certify
that all questions have been answered to my satisfaction. By submitting this form I release all rights to
any photographs/videos
taken of me and my tattoos. I also give consent in advance to their reproduction in prints and social
media.
Free Touch-up Policy
I acknowledge that tattoos done on scars, cover up tattoos, black out tattoos, finger tattoos, hand
tattoos and feet tattoos often
require a touch-up or a re-do within days or weeks of getting them done. I understand these are
problematic areas and situations.
These types of tattoos often do not hold as well as other spots on the body and require more work after
healing. If I need tattoos
mentioned above touched up, it would be at a full cost of whatever time it takes to do them. This
explantion is in addition to the
appointment info provided in your appointment information texted to you and emailed to you after booking.
READ ABOVE TOUCH UP POLICY!!
Numbing Cream Policy
I agree that if I use a numbing cream or any other 3rd party product, I do so at my own risk, assuming all
responsibility for any
reaction or poor healing and sacrificing my free touch-up. We will not do free touch-ups on a tattoo that
healed poorly due to numbing cream.
BOARD OF HEALTH - BODY ART DISCLOSURE STATEMENTS
This statement is to be given to all body art clients, and is to be signed by the client, prior to
performing any body art procedure.
TATTOO DISCLOSURE STATEMENT
As with any invasive procedure, tattooing may involve possible health risks. Pain, bleeding, febrile
illness, tetanus, systemic infection,
swelling, infection, scarring of the area, and nerve damage. Un-sterile equipment and needles can spread
infectious diseases; it is extremely
important to be sure that all equipment is clean and sanitary before a use. Tattoos and permanent makeup
are not easily removed and, in some cases,
may cause permanent discoloration. Think carefully before getting a tattoo. There is also the possibility
of an allergic reaction. The inks or dyes
used for tattoos are color additives. Currently, no color additives have been approved by FDA for tattoos,
including those used in permanent makeup.
Blood donations cannot be made for a year after getting a tattoo or permanent makeup.
THE BODY ART PRACTITIONER SHOULD
Properly and thoroughly cleanse the area before the procedure. Use sterilized equipment. Use sterile
techniques. Provide information on the aftercare of the area receiving body art.
HEALTH HISTORY AND INFORMED CONSENT
The following conditions may increase health risks associated with receiving body art:
- diabetes
- hemophilia (bleeding)
- skin diseases, lesions, or skin sensitivities to soaps, disinfectants etc.
- history of allergies or adverse reactions to pigments, dyes, or other sensitivities
- history of epilepsy, seizures, fainting, or narcolepsy;
- use of medications such as anticoagulants. (such as coumadin) which thin the blood and/or interfere
with blood clotting; and
- hepatitis or HIV infection
PROCEDURE FOR FILING A COMPLAINT
If there is any injury, infection, complication or disease as a result of a body art procedure notify this
establishment and the following local board of health at
Salisbury Health Dept., 5 Beach Road, Salisbury, Massachusetts 01952. Phone: 978-462-3430
CLIENT CONFIRMATION
I have received the above information; I do not have a condition that prevents me from receiving body art.
I consent to the performance of the body art procedure and will be provided written and verbal aftercare
instructions.
