Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

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Date

MM

DD

YYYY

Acknowledge by signing this form that I have been given full opportunity to ask any and all questions which I may have about obtaining a tattoo at Tattoo Shop in Leadville (tsl), and that all of my questions have been answered to my full satisfaction. I specifically acknowledge that I have been advised of the facts and matters set forth below and agree as follow; I, being of sound mind and body, acknowledge that the obtaining of my tattoo is by my choice alone and consent to the application of the tattoo and to any actions or conducts of the representatives of tsl reasonably necessary to perform the tattoo procedure: *

I agree to release and forever discharge and hold harmless tsl, its representatives and/or private contractors from any and all claims, damages or legal actions arising from or connected in any way with my tattoo for the procedures and conduct used to apply my tattoo: *

I acknowledge that a tattoo is a permanent change to my appearance and no representations have been made as to their ability to later change or remove my tattoo. I acknowledge that variations in color and/or design may exist between the tattoo that is selected by me and the actual tattoo that is applied to my body: *

I acknowledge that it is not reasonable for the representatives or contractors of tsl to determine whether I might have an allergic reaction to the dye, pigment or processes used in my tattoo, and I agree to accept the risk that such a reaction is possible: *

I acknowledged that I have received both written and verbal instructions regarding risk, outcome and aftercare: *

I have read and understand the tattoo aftercare instructions provided on tsl website: *

Are you pregnant or breastfeeding: *

yes

no

do you have any of the following: Hemophilia, HIV/AIDS, Staphylococcus, Diabetes, Hepatitis, Skin Disease or lesions: *

yes

no

Do you have or have you been treated for Methicillin-Resistant Staphylococcus Aureus (MRSA): *

yes

no

Do you have allergies or adverse reactions to latex, pigments, dyes, disinfectants, soaps or metals: *

yes

no

Artist name

Rosie

Tony

Guest Artist