Waiver Form

Date of Appointment *

MM

DD

YYYY

Acknowledgements *

I have truthfully represented myself to Hudson Valley Tattoo Company to be eighteen (18) years of age or older. To my knowledge, I do not have any physical, mental, or medical impairment or disability that might affect my wellbeing as a direct or indirect result of my decision to have any tattoo-related work done at this time. I acknowledge the receipt of written instructions advising me of the proper care of my tattoo, and I recognize the absolute necessity to follow these instructions. I agree to follow all instructions concerning the care of my tattoo while it is healing. I agree that any touch-up work needed due to my own negligence will be done at my own expense. I acknowledge that infection is always possible as a result of obtaining a tattoo, particularly in the event that I do not take proper care of my tattoo. I acknowledge that it is not reasonably possible for the representatives of Hudson Valley Tattoo Company to determine whether I might have an allergic reaction to the dyes, pigments or processes used in my tattoo, and I agree to accept the risk that such a reaction is possible. I do not have an allergy to latex products. I realize that variations in color and my design may exist between my tattoo selected by me and as ultimately applied to my body. 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. I acknowledge that the obtaining of a tattoo is by my choice alone, and I consent to the application of the tattoo and to any actions or conduct of the Hudson Valley Tattoo Company reasonably necessary to perform the tattoo procedure. I agree to pay for any and all damages and injuries to any and all persons and property belongings to Hudson Valley Tattoo Company, or any other persons to whom Hudson Valley Tattoo Company may become liable contractually or by operation of law, caused by or resulting from my decision to have my tattoo-related work done by Hudson Valley Tattoo Company. I agree to leave the premises of Hudson Valley Tattoo Company or any establishment where Hudson Valley Tattoo Company is engaged in business promptly upon request for any reason whatsoever by any agent or employee of Hudson Valley Tattoo Company. I agree, for myself, my heirs, assigns, and legal representatives, to release and forever discharge and hold harmless Hudson Valley Tattoo Company and its agents, employees, officers, and shareholders, from any any all claims, damages, or legal actions arising from or connected in any way with my tattoo or the procedures and conduct used to apply my tattoo. I specifically agree that this release shall be continuing in nature and shall apply not only to this tattoo but also to a subsequent treatment, application, or tattoos, which I contract to have applied or installed. This agreement constitutes the entire agreement between the patrons. Neither party shall be bound by any terms, conditions, or statements, oral or written, not herein contained. Each party hereby acknowledges that in executing this agreement he or she has not been induced, persuaded, or motivated by any promise or representations made by the other party, unless expressly set forth herein.

I accept all of the above.

If my picture is taken I give permission for it to be used in any form of media for advertising, promotional, or educational purposes with no compensation to myself. *

Yes

No

Do you have communicable disease? *

Yes

No

Are you currently on any medication that might interfere with getting a tattoo? *

(i.e. blood thinners, steroids, antibiotics)

Yes

No

Today's Date *

MM

DD

YYYY

Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country