American Gypsy Tattoo Company

Tattoo Release and Medical Disclosure

First name

Last name

Age

Birthday

Race

Sex

Lisy any allergies, including allergies to medications, topical solutions, and foods.

History of bleeding disorders?

yes

If you answered "yes" to the above question, please explain:

Have you ever been diagnosed with a communicable disease?

yes

Are you currently under treatment for any infectious disease?

yes

If you answered "yes" to either of the two questions above, please explain:

Are you currently pregnant or do you suspect you might be pregnant?

yes

Please, initial below that you have read, understand, and agree to the following statements:

I certify that I am of 18 years of age or older. If a minor, 16 to 17 years of age, a notarized signature of a parent or legal guardian must be presented along with proper identification.

I acknowledge and understand that this tattoo is a permanent alteration to my physical appearance.

I acknowledge and understand that the utmost care will be taken during my tattoo application process, and that the end result of my tattoo is greatly affected by the healing process.

I certify that I will follow all after care instructions given to me by the artist to the best of my ability.

Liability Release Statement

I, hereby acknowledge that I am voluntarily requesting a tattoo from American Gypsy Tattoo Company. I understand that tattooing involves the insertion of ink and pigments into the skin and carries inherent risks, including but not limited to infection, allergic reactions, scarring, and fading.

I have carefully considered the risks associated with tattooing and agree to assume full responsibility for any complications or adverse reactions that may arise. I release American Gypsy Tattoo Company, its employees, and agents from any and all liability for any injuries, damages, or complications resulting from the tattooing procedure.

I certify that I am of legal age to consent to this procedure and that I am not under the influence of alcohol or drugs. I have provided accurate and complete medical information to the tattoo artist.

I further acknowledge that American Gypsy Tattoo Company will be performing the tattoo using appropriate instruments and techniques as per Florida state regulations and guidelines.

By signing below, I affirm that I have read and understood this liability release and agree to its terms.

Signature

Please select your artist:

Tattoo Location

Date