Name:

Sex: MaleFemale

Address:

Zip:

Email:

Phone:

Emergency Contact

Name: University of Miami Hospital Phone: 305-689-5511

Personal Emergency Contact Name: Phone:

Physician Contact Name: Miami Urgent Care Phone: 305-494-0536

Address: 2645 Douglas Road Suite #502 Miami, FL 33133

MEDICAL HISTORY AND INFORMED CONSENT

1. If I have diabetes, epilepsy, hepatitis, hemophilia, HIV-AIDS or any other communicable disease, heart condition, take medicine, which thins the blood, I have advised my Tattoo Artist. I am not pregnant or nursing. I am not under the influence of alcohol or drugs. IF YES, PLEASE LIST:

2. I do not have medical or skin conditions such as but not limited to: acne, scarring (keloid), eczema, psoriasis, freckles, moles, or sunburn in the area to be tattooed that may interfere with said tattoo. IF YES, PLEASE LIST:

3. I acknowledge it is not reasonably possible for the representatives and employees of this tattoo shop to determine whether I might have an allergic reaction to the pigments or processes used in my tattoo, and I agree to accept the risk that such a reaction is possible.

4. I acknowledge that infection is always possible as a result of the obtaining of a tattoo, particularly in the event that I do not take proper care of my tattoo. I have received aftercare instructions and I agree to follow them while my tattoo is healing.

5. I understand that if I have any skin treatments, laser hair removal, plastic surgery, or other skin altering procedures, it may result in adverse changes to my tattoo.

6. I acknowledge that a tattoo is a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove my tattoo.

7. TOUCH UP POLICY: I agree that any touch-up work may be needed (ex: fine line tattoos, feet and finger tattoo placements). Tattoo Artists will allow ONE touch up within the year free of charge. Any touch up due to my own negligence will be done at my own expense.

8. STENCIL APPROVAL: I agree that both the Artist and the Tattoo Studio have given me the full opportunity to ask any and all questions about the application of my tattoo and all of my questions have been answered to my total satisfaction prior to the tattoo session. Neither the Artist nor the Tattoo Studio is responsible for the meaning or spelling of the symbol or text that I have provided/ approved to them or chosen from the flash (design) sheet.

9. To my knowledge, I do not have any physical, mental, or medical impairment or disability, which might affect my well-being as a direct or indirect result of my decision to have a tattoo done at R.A.W. Ink LLC.

Tattoo Description:

Location:

I, , acknowledge I am over the age of eighteen and that I have truthfully represented to my Tattoo Artist that the obtaining of a tattoo is by my choice alone. I consent to the application of the tattoo and to any actions or conduct of the representatives and employees of the tattoo shop reasonably necessary to perform the tattoo procedure. I agree for myself, my heirs, assigns and legal representations to hold R.A.W Ink LLC harmless of all damages, actions, causes of action judgements, cost litigation attorney, and all other cost and expenses which might artiste from my decision to have any tattoo related work done at R.A.W Ink LLC.

I understand that my footage taken at R.A.W. Ink LLC belongs to R.A.W Ink LLC and consent to its release.I agree and accept notifications from R.A.W Ink LLC.

How did you hear about us?

Printed Name of Artist:

Artist Signature:

PLEASE INSERT A PHOTO OF A GOVERNMENT ISSUED ID (passport, drivers license)

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