Consent Form | Avnas Tattoo

Consult a physician prior to the procedure if you have any concerns about the questions below.

Have you eaten within the last 4 hours?

Yes No

Are you under the influence of drugs or alcohol?

Yes No

Have you taken anticoagulants (heparin, warfarin), antiplatelet drugs, or NSAIDs in the last 24 hours?

Yes No

Are you taking medication that may affect wound healing?

Yes No

Do you have any allergies to pigments, latex, iodine, or other products?

Yes No

Do you have hemophilia, epilepsy, or conditions that may affect tattooing?

Yes No

Do you have any skin conditions that may affect healing?

Yes No

Do you have communicable diseases (hepatitis, HIV, etc.)?

Yes No

Do you have diabetes, high blood pressure, or heart conditions?

Yes No

I acknowledge I am NOT pregnant and I am not nursing at this time.

To my knowledge, I do not have any physical, mental or medical 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 have truthfully represented that I am over 18 (eighteen) years old with proper identification.

I agree to give the tattoo artist consent to publish any and all photos of my tattoo(s).

I acknowledge that all payments, both deposits and payments for services the day of the appointment, are non-refundable.

I acknowledge that my initial deposit allows for two rescheduled appointments. If I need to reschedule more than twice, an additional deposit will be necessary.

I acknowledge that the obtaining of my tattoo is by my choice alone and I consent to the application of the tattoo and to any actions or conduct of the tattoo artist, reasonably necessary to perform the tattoo procedure.

I agree to release and forever discharge and hold harmless, Pachamama Tattoo and its agents, employees, representatives, officers and shareholders from any and all claims, damages or legal actions arising from or connected in any way with my tattoo or procedures and conduct used to apply my tattoo.

I acknowledge that variation in color and design may exist between any tattoo selected by me and as ultimately applied to my body.

I acknowledge that it is not reasonably possible for the tattoo artist to determine whether I may have an allergic reaction to the dyes, pigments or processes used in my tattoo, and I agree to accept that this risk is a possibility.

I acknowledge that infections are always a possibility as a result of obtaining a tattoo, particularly in the event that I do not properly take care of my tattoo.

I acknowledge that tattoos may cause swelling, bruising, discomfort, bleeding, pain, allergic reactions, irreversible body changes, and may lead to infection and scarring.

If an adverse reaction or infection develops at the site of your tattoo, contact your personal physician for treatment and report to SNHD Special Programs at (702) 759-0677.

✽ Consent Form ✽