Black Dog StudioCONSENT FORM Name * Please write your name as it appears on your ID. If you have a different preferred name, please let me know! First Name Last Name Date * MM DD YYYY Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country How did you hear about me? * Please write the name of someone who referred you for my referral program, or the site through which you found me! Terms * Please check all. I have been fully informed of the inherent risks associated with getting a tattoo. I fully understand that these risks, known and unknown, can lead to injury including but not limited to: infection, scarring, difficulties in the detection of melanoma and allergic reactions to tattoo pigment, latex gloves and/or soap. Having been informed of these potential risks, I wish to proceed with the tattoo procedure and freely accept any and all risks that may arise. I WAIVE AND RELEASE to the fullest extent permitted by law any person of Black Dog Studio from all liability whatsoever, including but not limited to, any and all claims or causes of action that I, my estate, heirs, executors or assigns may have personal injury or otherwise, including any direct and/or consequential damages, which result or arise from the procedure and application of my tattoo. Black Dog Studio has given me the full opportunity to ask any question about the procedure and application of my tattoo and all of my questions, if any, have been answered to my total satisfaction. Black Dog Studio has given me instructions on the care of my tattoo while it's healing. I understand and will follow them. I acknowledge that it is possible that the tattoo can become infected, particularly if I do not follow the instructions given to me. If any touch-up work is needed due to my own negligence, I agree that the work will be done at my own expense. I am not under the influence of any drugs or alcohol, and I am voluntarily submitting to be tattooed by the Black Dog Studio artist without duress or coercion. I do no suffer from diabetes, epilepsy, hemophilia, heart condition(s), nor do I take blood thinning medication. I do not have any other medical or skin condition that may interfere with the procedure, 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 preventative regimen of antibiotics that is required by my doctor in advance of any invasive procedure such as tattooing. I am not pregnant or nursing. I do not have a mental impairment that may affect my judgment in getting the tattoo. I give Black Dog Studio artist(s) permission to post the image of my tattoo on their website and/or social media for marketing and portfolio-building purposes. Electronic Signature * By typing my name in this box, I acknowledge and agree to the above statements. Thank you!