Consent Form Name * First Name Last Name Date of Birth * MM DD YYYY Any allergies I need to be aware of? * Yes No If yes, please explain: Any other information I should be aware of? Pronouns * She/Her She/They He/Him He/ They They/Them Other (Please let me know your preference) Home Address * Emergency Contact * First Name Last Name Emergency Contact Phone Number * (###) ### #### Location and description of tattoo: * Do you consent to having your photo taken and used in Savannah's Digital Portfolio? * Yes No Are you currently under the influence of any drugs or alchohol? * Yes No Are you Pregnant or nursing? * Yes No Do you have any communicable diseases? * Yes No Do you have any Skin Conditions? * Yes No Do you have diabeties? * Yes No Do you have hemophilia? * Yes No Are you on any blood thinners? * Yes No Check the box to agree to each of the following statements: * I acknowledge that Savannah does not offer refunds after the procedure, but will touch up the piece for free if I am dissatisfied I agree that Savannah does not have any way of identifying if I am allergic to the elements or ingredients that will be used for my tattoo aside from common food/medical allergies discusses prior to the procedure I understand that I need to take care of my tattoo by following the instructions given to me by the artist. I understand that infection is a possibility if I don't follow the instructions given to me for the healing process of my tattoo. I indemnify and hold Savannah harmless against any claims, expenses, damages and liabilities I understand that I am entitled to change consent at any time during the tattoo process and I will inform Savannah if I begin to feel unsure, uncomfortable, ill, ect., I confirm that all the information I provided in this document is accurate and true. Type your first and last name to Digitally Sign this consent form: * Today's Date * MM DD YYYY Thank you!
