SUGARLOAF TATTOO PIERCING WAIVER

COBB AND GWINNETT COUNTY, GA STATE ONLY WAIVER / PLEASE PRESENT ID

Date*

Your Full Name*

PHONE NUMBER*

DATE OF BIRTH:*

Address (Street, City, State, Zip Code)*

ARTIST/PIERCER NAME? and LICENSE NUMBER?*

TATTOO or PIERCING?*

LOCATION ON BODY FOR TATTOO OR PIERCING?*

COMPLICATIONS WITH TATTOO/PIERCING?*

IF TATTOO, DESIGN?

IF COMPLICATIONS, EXPLAIN:

IF PIERCING FOR MINOR, MINORS NAME:

IF PIERCING FOR MINOR, MINORS DATE OF BIRTH:

*1. I do not have diabetes or any disorder or medication that affects the neurological or immune system in fighting infection.

*2. I do not have a blood borne condition such as Hepatitis B, Hepatitis C, HIV.

*3. I do not have history of hemophilia or any lesions, or skin sensitives to soap, disinfectants, etc.

*4. I do not have history of allergies or adverse reactions to pigments, dyes, or other skin sensitives.

*5. I do not have history of epilepsy, seizures, fainting, or narcolepsy.

*6. I am not currently taking medications such as aspiring or other anticoagulants (such as arfarin, xarelto, plavix, eliquis, etc.) which thin the blood and or interfere with blood clotting.

*7. I do not have history or suspicion of adverse reaction to latex or products containing latex.

*8. I do not have history of Keloid Formation.

*9. I am not pregnant and have been pregnant in the last three months.

*10. I have eaten in the last 4 hours.

*11. I am not under the influence of alcohol or drugs.

*12. I (you the client) am advised that I should consult a physician prior to any procedure by this location if I have any concerns related to any conditions. I (you the client) am advised that my Health conditions listed above may increase health risks associated with receiving a body art procedure from this location.

*IF COMPLAINTS AND ISSUES ARISE CONTACT THE DEPARTMENT PERTAINING YOUR PRESENT LOCATION: Gwinnett Environmental Health Services, 455 Grayson Highway, Lawrenceville, GA 30046 at 866-255-4293; or Cobb County Environmental Health Services, 1738 County Services Pkwy SW, Marietta, GA 30008 at (770) 435-7815.

*I AM VOLUNTARILY obtaining services here today at my own free will and volition. I have been given the opportunity to read and understand the documents presented. I have been given the ability and time to ask questions about my procedure. I have received and understand the written and verbal aftercare given to me.

ONLY SIGN IF REFUSING TO DISCLOSE INFORMATION LISTED ABOVE

*Tattoo is the permanent insertion of a pigment in a carrier fluid under the skin. I acknowledge by signing this Release that I have been given the full opportunity to ask any and all questions which I might have about obtaining a tattoo, piercing or jewelry change from the Artist/Piercer present at Black Cloud Piercing and Body Jewelry and all my questions have been answered by the staff/associates of this establishment. I have advised the Artist/Piercer of any allergies to metals, latex gloves, soaps and solutions. I acknowledge a piercing/tattoo is a perforation and will result in a permanent change in appearance, and that no representation has been made to me as to the ability to restore the skin involved in this piercing to is pre-piercing/tattoo condition. I agree to release and forever discharge and hold harmless the Piercer and all staff of Strategic Venture Solutions Inc. dba Black Cloud Tattoo, Black Cloud Piercing and Body Jewelry from any and all claims, damages or legal actions arising from or connected in any way with my piercing/tattoo, or the procedure and conduct used in my piercing. I agree to pay for any and all damages, court cost, attorney representing Strategic Venture Solutions Inc. or injuries to any and all persons and property of SVS, Inc. belonging to SVS, Inc., or any other person to whom SVS, Inc. and representatives may become liable contractually or by operation of law, caused by, or resulting from my decision to have any piercing-related work done by a representative of SVS, Inc.I have truthfully represented to Black Cloud Piercing and Body Jewelry and its associates I am over the age of 18 years or I am a Parent/Legal Guardian present. I attest that I am not using a false Identification to receive services or representing myself as someone else. I am not under the influence of drugs or alcohol. 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 piercing done at this time. I have read and understood each of the above paragraphs and I have been given a chance to translate this release form in any language or form of my understanding. I understand all aftercare instructions given to me verbally and/or in written form. Therefore I release Black Cloud Tattoo and Piercing (SVH, Corp.) from all if any claim that may result from my own care of my piercing/tattoo/service. ANY County Board of Health makes no guarantee there will be no injury due to the aforementioned procedure being performed.

Electronic Signature and Acknowledgement

Signature Required

Your Electronic Signature*