Release Form

Release form

Before you fill out the form below please read our aftercare instructions.

"*" indicates required fields

Legal Name*

First Last

Nickname/Name you'd like us to refer to you

Pronoun(s)

Email*

Enter Email Confirm Email

Phone*

Birthdate*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Appointment Date*

Appointment Time*

Choose your Artist*

Description of Design and Placement (body)*

E.g: infinity Symbol; left upper arm

Health*

I agree

I disagree

I do not have diabetes, epilepsy, hemophilia, or a heart condition, nor do I take blood-thinning medication. I do not have any other medical or skin condition that may interfere with the application or healing of the tattoo. I am not the recipient of an organ or bone marrow transplant or, if I am, I have taken the prescribed preventive regimen of antibiotics that is required by my doctor in advance of any invasive procedure such as tattooing or piercing. I am not pregnant or nursing. I do not have a mental impairment that may affect my judgment in getting the tattoo.

Health Continued*

Please explain why you marked disagree above.

Would you like to be tagged in photos on instagram

Yes

If yes, what is your instagram username?

Additional Info

Photo of your ID*

Max. file size: 300 MB.

Must be a GOVERNMENT issued PHOTO identification showing that you are 18 years of age or older. Parental Consent does not apply in Oregon

Signature*

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Phone

This field is for validation purposes and should be left unchanged.