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Forbidden Anchor Tattoo LLC Authorization Form
(Tattoo)

 

Safe Body Art Act Agreement

  • Tattooing involves the placement of pigment into the epidermis of the skin, the layer of dermal tissue underlying the epidermis. After initial injection, the pigment is dispersed throughout a homogenized damaged layer down through the epidermis and upper dermis, in both of which the presence of foreign material activates the phagocytes (macrophages) of the immune system to engulf the pigment particles. As healing proceeds, the damaged epidermis flakes away (eliminating surface pigment) while deeper in the skin, granulation tissue forms. This is later converted to connective tissue by collagen growth. This mends the upper dermis, where pigment remains trapped with fibroblasts, ultimately concentrating in a layer just below the dermis/epidermis boundary. It's presence there is stable, but in the long term (decades) the pigment tends to migrate deeper into the dermis, accounting for the degraded detail of old tattoos.

I Agree
 

  • I acknowledge I am over the age of 18 and that I have truthfully represented to my tattoo artist that the obtaining of this tattoo is by my choice alone. I consent to the application of the tattoo and any actions necessary to perform the procedure. 

I Agree

  • I am not pregnant or nursing. I do not have epilepsy. I do not suffer from any heart conditions, such cardiac valve disease, or take medication which thins the blood. I have informed my tattoo artist of any condition, such as diabetes, that might hamper healing of the tattoo. I do not have hepatitis, H.I.V, hemophilia, or other bleeding disorders. I have no history of herpes infection at proposed procedure site or any other communicable diseases. I am not currently using medication, including being prescribed antibiotics prior to dental or surgical procedures. 

I Agree

  • I am not under the influence of drugs or alcohol. To the best of my knowledge, I do not have any physical, mental, or medical impairments / disability that might affect my well being as a direct or indirect result of my decision to have any tattoo related work done at this time. 

I Agree

  • I do not have medical or skin conditions such as but not limited to: acne, scarring (keloid), eczema, psoriasis, freckles, moles or sunburn, in the area to be tattooed, that may interfere with the tattoo process. 

I Agree

  • I acknowledge it is not reasonably possible for the representatives and employees of Forbidden Anchor Tattoo to determine whether I might have an allergic reaction to latex, antibiotics, or the pigments / processes used in my tattoo, and I agree to accept the risk that such a reaction is possible. 

I Agree

  • I agree for myself, my heirs, assigns and legal representatives, to hold Forbidden Anchor Tattoo harmless from all damages, actions, causes of action, claim judgements, costs of litigations, attorney's fees, and all other costs and expenses, which might arise from my decision to have any tattoo related work done by Forbidden Anchor Tattoo. 

I Agree

  • I understand I will be tattooed using sterilized instruments and appropriate techniques. I understand that this type of tattoo usually takes up to two (2) weeks or longer to heal. I acknowledge that infection is always possible as a result of obtaining a tattoo, particularly in the event that 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, due to my own negligence, will be done at my own expense. 

I Agree

  • Tattoo inks, dyes, and pigments are not approved by the Food and Drug Administration (FDA). 

I Agree

  • I realize that variations in color and design may exist between any tattoo as selected by me and as ultimately applied to my body. I understand that if my skin color is dark, the colors will not appear as bright as they do on light skin. I understand that if I have any skin treatments such as laser hair removal, plastic surgery, or other skin altering procedures, it may result in adverse changes to my tattoo. 

I Agree

  • 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 / cover / alter my tattoo. 

I Agree

  • I agree that these waivers also pertain to and are designed to protect any and all establishments where Forbidden Anchor Tattoo conducts business. 

I Agree

  • I release all rights to any photographs taken of me and the tattoo and give consent in advance to their reproduction in print or electronic form. 

I Agree

​I agree to all the aforementioned terms

 

COVID-19 Agreement

In accordance with the directions from the State of California, Forbidden Anchor Tattoo LLC, and its sole member(s), (collectively the ‘Shop’), in conjunction with the other service providers (collectively the “Artists) who work in the Shop’s premises located at 4485 San Pablo Ave Unit 4 Palm Desert, CA 92260 (the premises), have updated the Shop’s operating policies and procedures in an effort to promote a healthy and safe environment for the Shop, the Artists, and their clients. 

 

In consideration for receiving any/all in person body art services from the shop and the artists on the premises, or for being allowed to remain on the premises while accompanying someone who is receiving such services, I, the undersigned for and on behalf of myself and all children under the age of eighteen years that I have brought with me, state as follows:

 

  • I am aware of the potential hazards of the novel coronavirus (COVID-19) and of the general guidelines established by the Centers for Disease Control and Prevention (‘CDC’) and the California Department of Public Health for the public to deal with such hazards. I hereby acknowledge and agree that all of the potential hazards of COVID-19 and how it is transmitted to and among members of the public are not yet fully known and understood and that, accordingly, the CDC and California Department of Public Health guidelines are periodically modified and/or updated to reflect new developments in such knowledge and understanding. I accept the responsibility to keep myself familiar with all such guidelines as they may be changed from time to time hereafter. I also hereby represent and warrant that, during the fourteen days prior to the date of filing this Waiver of Liability, neither I nor anyone with whom I have been in contact has been diagnosed with COVID-19 or has had any of the following symptoms: cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headaches, sore throat, or a new loss of taste or smell.

I Agree

  • I further acknowledge and agree that, even though the shop and artists are following all of the laws, rules, policies, procedures and guidelines set forth by the Order of the State of Public Health Officer of California and the California Code of Regulations and/or established by the CDC and the California Department of Public Health and made applicable to the shop and the premises, neither the shop nor the artists can guarantee my health and safety, or the health and safety of any person who may be accompanying me. Notwithstanding the foregoing, and with a full understanding and appreciation of the known and unknown risks associated with COVID-19, I hereby knowingly and voluntarily choose to remain on the premises and/or receive the body art services provided by the shop and/or by the artists, and I further hereby expressly ASSUME ALL RISKS related to my contracting of COVID-19 and/or any other infectious disease as a result of my receipt of such body art services and/or presence on the premises. 

I Agree

  • I further hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE the shop (including any/all of the artists including my artist, and any and all of their employees, agents, and other representatives, all of whom are collectively hereinafter referred to as the ‘Releasees’ of and from any and all liability related in a way to my (and my children’s, if applicable) contraction of COVID-19 or any other infectious disease as a result of any negligence of the Releasees. 

I Agree

  • I further hereby agree to DEFEND, INDEMNIFY AND HOLD HARMLESS the Releasees of, from and against any and all claims, demands, suits, judgements, losses or expenses, of any kind or nature whatsoever (including, without limitation, attorney’s fees, costs and disbursements), which arise in any way out of my (and my children’s if applicable) contradiction of COVID-19 or any other infectious disease as a result of any negligence of the Releasees. 

I Agree

  • It is my express intent that this Waiver of Liability and Hold Harmless Agreement (‘Agreement’) shall be forever binding upon me and all of my heirs, executors, administrators, successors and assigns, and it shall be construed, interpreted and governed by and in accordance with the laws of the State of California. 

I Agree

  • I FURTHER HEREBY KNOWINGLY AND VOLUNTARILY WAIVE ANY RIGHT TO A JURY TRIAL OF ANY DISPUTE ARISING OUT OF THIS AGREEMENT, I FINALLY HEREBY ACKNOWLEDGE AND AGREE THAT MY EXECUTION OF THIS AGREEMENT IS A MATERIAL INDUCEMENT TO THE RELEASEES PROVISION OF THE SERVICES TO ME OR TO THE PERSON WHOM I AM ACCOMPANYING ON THE PREMISES.

I Agree

IN WITNESS WHEREOF, I HEREBY ACKNOWLEDGE, REPRESENT, WARRANT AND AGREE that I have read the foregoing Agreement, understand it, and am signing it voluntary as my own free act and deed; that no oral representations, statements, or inducements of any kind have been made to me by the RELEASEES; that I am at least (18) years of age and am fully competent to execute this Agreement; and that I have executed this Agreement for full, adequate and complete consideration with the intent to be forever legally bound hereby.

​I agree to all the aforementioned terms

First Client Name

First Name*

Last Name*

Phone*
First Client Date of Birth*
First Client Gender/Preferred Gender Pronoun

Gender/PGP
First Client Signature*
Second Client Name

First Name*

Last Name*
Second Client Date of Birth*
Second Client Gender/Preferred Gender Pronoun

Gender/PGP
Third Client Name

First Name*

Last Name*
Third Client Date of Birth*
Third Client Gender/Preferred Gender Pronoun

Gender/PGP
Fourth Client Name

First Name*

Last Name*
Fourth Client Date of Birth*
Fourth Client Gender/Preferred Gender Pronoun

Gender/PGP
Fifth Client Name

First Name*

Last Name*
Fifth Client Date of Birth*
Fifth Client Gender/Preferred Gender Pronoun

Gender/PGP
Sixth Client Name

First Name*

Last Name*
Sixth Client Date of Birth*
Sixth Client Gender/Preferred Gender Pronoun

Gender/PGP
Seventh Client Name

First Name*

Last Name*
Seventh Client Date of Birth*
Seventh Client Gender/Preferred Gender Pronoun

Gender/PGP
Eighth Client Name

First Name*

Last Name*
Eighth Client Date of Birth*
Eighth Client Gender/Preferred Gender Pronoun

Gender/PGP
Ninth Client Name

First Name*

Last Name*
Ninth Client Date of Birth*
Ninth Client Gender/Preferred Gender Pronoun

Gender/PGP
Tenth Client Name

First Name*

Last Name*
Tenth Client Date of Birth*
Tenth Client Gender/Preferred Gender Pronoun

Gender/PGP
Client Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
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Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
Tattoo Information
Artist Name*

Tattoo Design Description *

Location on Body *
How did you hear about us?*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Gender/Preferred Gender Pronoun

Gender/PGP
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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