Release Form

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Name

First

Last

Birth Date

Date of Birth

DL Number

Drivers License Number

ID - Issuing State

Issuing State

Expiration Date

Expiration date for State Issued ID

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Agreement

I acknowledge that by signing this agreement that I have been given ample opportunity to ask any and all questions which I might have about the process of obtaining a tattoo and that all questions have been answered to my full satisfaction. I specifically acknowledge that I have been informed of the facts and matters outlined below and I agree as follows:

Agreement

If I have any condition, medical or otherwise, that might affect the process of applying or healing this tattoo, I have advised my tattooer. I am not pregnant or nursing. I am not under the influence of alcohol or drugs.
I do not have medical or skin conditions including but not limited to the following: acne, scarring (keloid), eczema, psoriasis, freckles, moles, or sunburn in the area to be tattooed that may interfere with said tattoo. If I have any type of infection or rash ANYWHERE on my body, I have advised my tattooer.
I acknowledge it is not reasonably possible to for the representatives/employees of this tattoo shop to determine whether I may have an allergic reaction to pigments or processes used in my tattoo, and I agree and accept the risk that such a reaction is possible.
I acknowledge that infection is always possible as a result of obtaining a tattoo, particularly in the event I do not take proper care of my tattoo. I have received aftercare instructions and I agree to follow them while my tattoo is healing. I agree that any touch up work needed will be done at my own expense, unless the tattooer decides otherwise.
I realize that variations in the color and design may exist between the tattoo as selected by me and the tattoo as it is applied to my body. I understand that on darker skin tones inks may not appear as vividly as they do on lighter skin tones.
I understand that if I have any skin treatments, laser hair removal, plastic surgery, or other skin altering procedures, it may result in aadverse changes to my tattoo.
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. To my knowledge, I do not have a physical, medical, or mental impairment or disability which might affect my well being as a direct or indirect result of my decision to have a tattoo.
I acknowledge that I am over the age of 18 and have truthfully represented to my tattooer that the obtaining of a tattoo is by my choice alone. I consent to the application of the tattoo and to any actions of the representatives and employees of the tattoo shop reasonably necessary to perform the tattoo procedure.
I have let my artist know about any birth control implant or any other medical implant device I may have, and have appropriate medical clearance to receive a tattoo procedure, and/or accept full responsibility for any repercussions/consequences that may come from said procedure.

I have read the above information and understand that this is a legally binding document, and that by signing I agree to and am bound by its terms.

Signature

Agreement Signature

Name

First

Last

Date Signed

Agreement

Salt Lake County Compliance Form