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Concent Form
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Concent Form
 
Please Print this form and bring it along with you to your appointment.  Also have your photo ID with you. 
 
Thank You,
    East Coast Dermagraphics

East Coast Dermagraphics
Tattoo And Piercing

Consent To Application of Tattoo Or Piercing and Waiver Of All Claims

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 as follows:
 
     (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**
_______________________________________
Please Print!
 
Date:_______________     Artist:___________________________
 
Name:__________________________________________
 
Phone:_________________________
 
Address:________________________________
 
 
City, State, Zip:________________________________
 
Date of Birth:________________    Age:_______
 
Body Design and Location:_________________________
 
Signature:__________________________________