I acknowledge by signing this agreement that I have been given the full opportunity to ask any questions which I might
have about obtaining a tattoo or piercing from East Coast Dermagraphics and that all my questions have been answered to my
satisfaction. I specifically acknowledge that I have been advised of the facts and matters set forth below, and agree
(1) I am not a hemophiliac (bleeder). I do not have diabetes, epilepsy, HIV, AIDS or any
other communicable disease. I am not under the influence of alcohol and/or drugs.
(2) I acknowledge that it is not reasonably possible for the representatives and employees of
East Coast Dermagraphics to determine whether I might have an allergic reaction to the pigments or the process used in my
tattoo or piercing and I agree to accept the risk that such is possible.
(3) I acknowledge that infection is always possible as a result of obtaining a tattoo or piercing,
particutarly in the event that I do not take proper care of my tattoo of piercing and I agree to follow all instructions concerning
the proper care of my tattoo or piercing while it is healing. I agree that any touch up work needed due to my own negligence
will be at my own expense.
(4) I realize that variations on color and design may exist between any tattoo as selected by
me and as ultimately applied to my body. I understand that if my skin color is dark the colors will not appear as bright
as they do on light skin.
(5) I acknowledge that a tattoo or piercing is a permanent change to my appearance and that
no representations have been made to me as to the ability to later remove any tattoo or piercing. 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 any tattoo or piercing related work done at this time.
(6) I acknowledge that I have truthfully represented to the employees and representatives of
East Coast Dermagraphics that I am over eighteen (18) years old and that the following information is true and correct.
(7) I acknowledge that obtaining my tattoo or piercing is by my choice alone and I consent to
the application of the tattoo or piercing and to any action or conduct of the employees of East Coast Dermagraphics reasonably
necessary to perform the tattoo or piercing procedure.
(8) I agree to release and forever discharge and hold harmless East Coast Dermagraphics and
its employees from any and all claims, damages, and legal action arising or connected in any way with my tattoo or piercing
of the procedures and conduct used to apply my tattoo or piercing.
**YOU MUST BE AT LEAST 18 YEARS OLD**
City, State, Zip:________________________________
Date of Birth:________________ Age:_______
Body Design and Location:_________________________