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Evolve Tattoo Collective Client Release Form
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Indicates required field
Todays Date
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SECTION 1. PATRON'S INFORMATION
Patron's Name
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First
Last
Patron's Date of Birth ( 00/00/0000 format please )
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Patron's Address
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Patron's Residence Phone Number
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Patron's Driver's License Number
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Procedure to be performed
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Tattoo
SECTION 2. MEDICAL/HEALTH ASSESSMENT - QUESTIONS TO BE ANSWERED BY PATRON.
Are you currently or have you ever used medications that contain a controlled substance?
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Yes
No
Have you ever been diagnosed by a medical doctor as to having contracted communicable disease such as Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens? If so, when?
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Yes
No
If answer to last question is Yes, complete answer here.
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Have you ever been diagnosed by a medical doctor as having allergies?
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Yes
No
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?
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Yes
No
Are you currently under the influence of any illegal substances?
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Yes
No
Are you currently under the influence of an alcoholic beverage?
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Yes
No
Have you been diagnosed with jaundice in the past twelve months?
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Yes
No
Are you currently using any medications that contain blood thinners?
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Yes
No
Are you currently using any medications that weaken the immune system thats fights infection?
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Yes
No
SECTION 3. TO BE COMPLETED BY THE PATRON.
I **enter name below**
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acknowledge that I am aware certain medical conditions and treatments and/or medications used to treat those medical conditions may be adversely impacted by the procedure(s) of tattooing and/or body piercing. Such medical conditions include but are not limited to, impaired kidney and/or liver function, diabetes, jaundice, medication containing blood thinners that weaken the immune system.
I further acknowledge that the tattoo should be considered permanent; that said tattoo can only be removed with a surgical procedure; and that any affective removal mat leave permanent scarring and disfigurement.
I hereby release, discharge, and hold harmless the tattoo shop, it's owners, employees, and agents from any and all liability, claims, actions, demands, causes of action, cost, and expenses, whether known or unknown, arising out of or in any way connected with any harm, injury, damage, or loss that may occur as a result of the tattooing procedure.
I have read this form and confirm that all the information i have given is correct, I understand that this is a consent form and I agree to be legally bound to it.
Agreement to Section 3. By checking this box I give my consent and agreement.
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Consent and agreement.
Name/Signature (Type name to render as signature)
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Upload a picture of Patron's ID (may be state issued license, or passport)
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Max file size: 20MB
The section below is to be filled out by your tattoo artist.
SECTION 4. THIS SECTION TO BE COMPLETED BY PRACTITIONER.
I **SELECT NAME OF PRACTITIONER**
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JASON PHILLIPS
TRAVIS RITTENHOUSE
LEE HARDING
MICHAEL CARLSON
BEN WEAS
have reviewed this consent form and have advised the above named patron both in writing and verbally of the dangers and contraindications of the procedure that sis to be performed.
By checking this box I hereby render this as my signature of the practitioner listed above. (Full signature on file)
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Render as signature of practitioner.
Practitioners License
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I, practitioner, have license on file.
Form to be submitted by Practitioner.
Submit
Home
Jason Phillips
Travis Rittenhouse
Lee Harding
Michael Carlson
Ben Weas
Evolve Events
Hiring Inquiry
Tattoo Aftercare Instructions
Retail
Contact Us
Blog
