SAGE INK CUSTOM TATTOO

MEDICAL HISTORY CONSENT AND RELEASE FORM

Please check any conditions listed below that apply to you.

How long has it been since you last ate? ____________________________________________________________________

Do you have any allergies? ______________________________________________________________________________

Are there any other known MEDICAL or SKIN CONDITIONS that may affect your TATTOO procedure?

_______________________________________________________________________________________

I HAVE READ AND UNDERSTOOD AND AGREE TO THE FOLLOWING:

·       I hereby certify that to the best of my knowledge this information is correct.

·       All Questions have been answered to my satisfaction.

·       I agree the said TATTOO is correctly drawn to my specifications.

·       I understand that the said TATTOO is PERMANENT.

·       This is to certify that I am at LEAST 18 YEARS OF AGE.

·       I am not under the influence of ALCOHOL OR DRUGS and am voluntarily submitting to be TATTOOed by SAGE-INK Custom TATTOO without duress or coercion.

·       I understand there is a possibility of an allergic reaction.

·       I understand there is a possibility of an infection.

·       I agree to follow all instructions concerning the care of my TATTOO, and that any touch-ups needed due to my own negligence will be done at my own expense.

·       Variations in color and design may exist between the TATTOO art I have selected and the actual TATTOO when it is applied to my body. I also understand that over time, colors and the clarity of the TATTOO will fade due to unprotected exposure to the sun and the naturally occurring dispersion of pigment under the skin.

·       I understand that there is a chance I might feel lightheaded, dizzy during or after being TATTOOed.

·       I agree to immediately notify the artist in the event I feel lightheaded, dizzy and/or faint before, during or after the procedure.  Failure to do so releases SAGE-INK Custom TATTOO and ARTISTS of all responsibility.

·       I hereby release SAGE-INK Custom TATTOO and ARTISTS of all responsibility and from all liability whatsoever for personal injury or otherwise for the said TATTOO.

·       ______(please initial) I release all rights to any photographs taken of me and/or the TATTOO and give consent in advance to their reproduction in print or electronic form.

By signing this release, I agree to all clauses above(except photo release if not initialed)

Signature_________________________________________Date____________________________

Address______________________________________City___________ State_____ Zip_________

Phone___________________EMAIL Address_______________________________________

DOB__________________ Age____________ ID?____________________________________

SAGE-INK CUSTOM TATTOO

                                               4625 SE Woodstock, Portland OR

                                        503-407-7062    metamick@sage-ink.com