Waiver Form

Date of Appointment *

MM

DD

YYYY

Acknowledgements *

I have truthfully represented myself to Hudson Valley Tattoo Company as eighteen (18) years of age or accompanied by a legal guardian. To my knowledge, I do not have any physical, mental, or medical impairment or disability that 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. I acknowledge the receipt of written instructions advising me of the proper care of my tattoo or piercing, and I recognize the absolute necessity to follow these instructions. I agree to follow all instructions concerning caring for my tattoo/piercing while it is healing. I agree that any tattoo touch-up work needed due to my negligence will be done at my own expense. I acknowledge that infection is always possible after obtaining a tattoo or piercing, particularly if I do not take proper care of it. I acknowledge that Hudson Valley Tattoo Company representatives cannot reasonably determine whether I might have an allergic reaction to the dyes, pigments, metals, or processes used in my tattoo or piercing. 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 design may exist between the tattoo I selected and the one that is ultimately applied to my body. I acknowledge that a tattoo or piercing permanently changes my appearance and that I have not been informed of the ability to later change, remove, or restore the skin to its pre-piercing condition. I acknowledge that obtaining a tattoo or piercing is my choice alone, and I consent to applying the tattoo or piercing and to any actions or conduct of the Hudson Valley Tattoo Company reasonably necessary to perform the tattoo or piercing 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 or piercing-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 or piercing. I specifically agree that this release shall be continuing in nature and shall apply not only to this tattoo or piercing but also to a subsequent treatment, application, tattoos nor piercings, which I contract to have applied or installed. This agreement constitutes the entire agreement between the parties. 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 or piercing? *

(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