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ROOTED BODY LLC CONSENT FORM

Please take your time filling out this form with the most recent and accurate information possible. Thank you!

First Name

Last Name

Contact Information

Phone

Email Address

Birth Month

Day

Gender

Race

Driver License #

Year

Age

Address

Emergency Contact Info

First Name

Last Name

Phone

Relationship

Address

Medical History

Have you ever had a tattoo before? *

Yes

No

Are you currently pregnant? *

Yes

No

Are you currently under the influence of alcohol or drugs, prescribed or otherwise? *

Yes

No

Have you ever had or do you currenty have any of the following:

Any heart condition

Epilepsy

Diabetus

Hemophilia or any bleeding disorder

Any communicable disease

Allergies

Any medical or skin condition at the location of tattooing

If so, please elaborate so that we may provide you with the safest care possible:

By checking each box you agree to the following: * Required

To my knowledge, I do not have any mental or medical impairment or disability which might affect my wel being as a direct or indrect result of my decision to have any tatto and/or piercing porcedure done at this time.

I agree to follow all instructions concerning the care of my tattoo and/or piercing while it is healing. I agree that any touch up work, due to my negligence, will be done at my own expense.

I understand and acknowledge that there is a risk of allergic reactions to tattoo ink, aftercare products, or other materials used during the tattoo process, as well as the potential for infection if aftercare instructions are not properly followed. I have been advised to seek medical attention immediately if any signs of an allergic reaction or infection occur, including but not limited to rednes

I understand that if my skin color is dark, the colors will not appear as bright as they do on lighter skin. Additionally, I understand that the finished tattoo may vary somewhat in appearance, color, and/or design from the drafts, drawings, photos, or other sources on which the tattoo were based.

Being of sound mind and body, I hereby release any and all employees, agents, or persons representing Rooted Body Tattoo from all responsibility. I agree not to sue Rooted Body Tattoo, its heirs, or assigns in connection with any or all damages, claims, demands, rights, and causes of action of any kind or nature based on inuries or property damages that arise from my decision to be tattooed.

I agree for myself, my heirs, assigns, and legal representitives to hold harmless from all damages, actions, causes of action, claim judgements, costs of litgations, attorney's fees and all other costs and expenses which might arise from my decision to have any tattoo work done by Rooted Body Tattoo.

I have been advised that the tattoo will be permanent and that it can only be removed with a surgical procedure, and that any effective removal will leave permanent scarring and disfigurement. This cautionary notice is required to be provided to me by the health department and hereby acknwoledge receipt of this formal notice.

I agree to pay for any and all damages and injuries to any persons and property belonging to Rooted Body Tattoo or any other person to whom they may become liable contractually or by operation of law, caused by or resulting from my decision to have any tatto work by Rooted Body Tattoo.

I hereby grant irrevocable consent to and authorize the use of any reproduction by Rooted Body Tattoo, any and all photographs which are taken this day of me without further compensation to me. All negatives, together with the prints, video, or live internet stream shall become and remain the property of Rooted Body Tattoo, solely and completely.

I am over the age of 18

Who is your artist today?

Please attach a photo of your ID:

Upload/Take Photo

Please make sure the photo is in focus

Today's date

Where will your tattoo be located?

Please add a short description of your tattoo:

Your Signature

I swear or affirm and agree that the above information is correct.

Artists Signature

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