Consent Form Name * First Name Last Name Age * Birthdate * MM DD YYYY Phone * (###) ### #### Email * Instagram Handle * Date of Appointment MM DD YYYY Pre-Procedure Questions Are you under the influence of drugs or alcohol? * Yes No Are you pregnant or nursing? * Yes No Do you have a communicable disease? * Yes No Do you have any skin conditions? * Yes No Skin conditions (e.g. Rashes, eczema, infection, psoriasis, scars, freckles, etc.) * If yes, please identify the condition. If I have diabetes, epilepsy, hepatitis, hemophilia, HIV-AIDS or any othercommunicable disease, heart condition or take Accutane, or medicine which thins the blood I have advised my tattooer. * If yes, please advise. Acknowledgement and Waiver I acknowledge that a tattoo is a permanent change to my appearance and do nothold my tattooer liable for or of the ability to later change or remove my tattoo. * Yes No I allow my tattoo to be photographed and be used for Kaelee Boussarie's portfolio. * Yes No I acknowledge it is not possible for Kaelee Boussarie to determine whether I might have an allergic reaction to the pigments or processes used in my tattoo, and I agree to accept the risk that such a reaction is possible. * Yes No I acknowledge that the Kaelee Boussarie does not offer refund. * Yes No I acknowledge that infection is always possible as a result of the obtaining of a tattoo, particularly in the event that I do not take proper care of my tattoo. I agree to follow aftercare instructions while my tattoo is healing. * Yes No I understand that I need to take care of the tattoo by following the instructions given to me by Kaelee Boussarie. * Yes No I realize that variations in color and design may exist between any tattoo as selected by me and as ultimately applied to my body. * Yes No I understand that if I have any skin treatments, laser hair removal, cosmeticsurgery or other skin altering procedures, it may result in changes to my tattoo. * Yes No I acknowledge I am over the age of eighteen and that I have truthfully represented to my tattooer that the obtaining of a tattoo is by my choice alone. * Yes No I fully understand the tattoo artist does not act as a medical professional. * Yes No I agree to release and discharge my artist from any and all claims, damages, orlegal actions arising from or connected to my tattoo and the procedure used in the application of my tattoo. * Yes No I confirm that the information I provided in this document is accurate and true. * Yes No I consent to the application of the tattoo. My tattoo artist, Kaelee Boussarie, and I recognize that I may revoke this consent at any time before or during the tattoo procedure. * Yes No Signed Date * MM DD YYYY Client Signature * Type full name as appears on ID Thank you!
