Consent & Waiver Form

Please fill out this form completely before your appointment

Personal Information

First Name *Last Name *

Email *Phone *

Date of Birth *Street Address

CityStateZIP Code

Emergency ContactContact Name

Contact PhoneRelationship

Service InformationType of ServiceService Description

Medical InformationKnown AllergiesCurrent MedicationsMedical Conditions

I am currently pregnantI am currently nursing

Recent Illness or Surgery

Consent & Release

Please Read Carefully

I acknowledge that I am voluntarily requesting the services described above. I understand that the procedure carries certain risks including, but not limited to: infection, allergic reactions, scarring, discoloration, and dissatisfaction with results. I have been given the opportunity to ask questions and have received satisfactory answers.

I certify that all information provided above is true and accurate. I agree to follow all aftercare instructions provided and understand that failure to do so may affect healing and final results.

I release and hold harmless the artist and studio from any liability for damages or claims arising from this procedure, except in cases of gross negligence.

I certify that I am 18 years of age or older *I have read and understand the procedure and aftercare instructions *I understand and accept the risks associated with this procedure *I consent to photos being taken for portfolio/promotional use (optional)I agree to the release and waiver of liability stated above *

SignatureFull Name (Type to Sign) *Date *

By submitting this form, you agree that a PDF copy will be sent to your email and the studio.