❖ cosmikali tattoo ❖ intentional body adornments ❖

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cosmikali

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cosmikali

English

Please fill out this consent and information form before our tattoo procedure. This must only be done once per client.

By completing and signing this form, you are releasing Cosmikali Tattoo and her associates from liability. Please read thoroughly until the end of the document. Check off each box, every field is required. I must receive this in my email in order to begin your tattoo.

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Email *

Today's date *

MM

DD

YYYY

Where are we tattooing today? (Location on your body) *

Is this your first time undergoing a body art procedure? (Is this your first tattoo?) *

Yes

No

Is this your first time working with Gaia aka Cosmikali Tattoo? *

Yes

No

Legal name *

❖ I, the aforementioned, have been fully informed of the risks associated with getting a tattoo. I fully understand that these risks, known and unknown, can lead to injury including but not limited to: infection, scarring, difficulties in the detection of melanoma and allergic reactions to tattoo pigment, aftercare products and/or soap. Having been informed of the potential risks associated with getting a tattoo I wish to proceed with the tattoo procedure and application and freely accept and expressly assume any and all risks that may arise from tattooing. *

I understand and agree

❖ Cosmikali has provided me instructions on the care of my tattoo while it's healing. I understand and will follow them. I acknowledge that it is possible that the tattoo can become infected, particularly if I do not follow the instructions given to me. If any touch-up work to the tattoo is needed due to my own negligence, I agree that the work will be done at my own expense.

Yes

❖ I WAIVE AND RELEASE to the fullest extent permitted by law the tattoo artist from all liability whatsoever, including but not limited to, any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise from the procedure and application of my tattoo, whether caused by the negligence or fault of either the artist or any person associated. *

I understand and agree

❖ Cosmikali Tattoo and her associates have given me the full opportunity to ask any question about the procedure and application of my tattoo and all of my questions have been answered to my satisfaction. *

Yes

❖ I am not under the influence of alcohol or drugs, and I am voluntarily submitting to be tattooed by the artist without duress or coercion. I will maintain sobriety throughout the procedure in order to give enthusiastic positive consent. *

Yes

❖ I do not suffer from diabetes, epilepsy, hemophilia, heart condition(s), nor do I take blood thinning medication. ❖ I do not have any other medical or skin condition that may interfere with the procedure, application or healing of the tattoo. I am not the recipient of an organ or bone marrow transplant or, if I am, I have taken the prescribed preventative regimen of antibiotics that is required by my doctor in advance of any invasive procedure such as tattooing or piercing. ❖ I am not pregnant or nursing. I do not have a mental impairment that may affect my judgement in getting the tattoo. I am not currently on antibiotics. ❖ I have informed my tattoo artist of all relevant medical information. *

Yes

❖ I am not allergic to lidocaine, and consent to the use of a lidocaine solution as a numbing agent during the application of my tattoo. If you are allergic to lidocaine or do not want it to be used, please inform your tattoo artist prior to beginning the procedure. *

Yes

No

❖ Variations in color and design may exist between the tattoo art I have selected and the actual tattoo when it is applied to my body. I also understand that over time, the colors and the clarity of my tattoo will fade due to unprotected exposure to the sun and the naturally occurring dispersion of pigment under the skin. ❖ A tattoo is a permanent change to my appearance and can only be removed by laser or surgical means, which can be disfiguring and/or costly and which in all likelihood will not result in the restoration of my skin to its exact appearance before being tattooed. *

I understand and agree

❖ Photo release: I release the right to any photographs taken of me and the tattoo and give consent in advance to their reproduction in print or electronic form. *

Yes

No (please speak of reasoning with your artist)

❖ PLEASE ASK YOUR ARTIST ABOUT THE PRICE OF YOUR TATTOO BEFORE BEGINNING THE PROCEDURE - it is your responsibility to confirm the price of the tattoo, and we assume no responsibility for any misunderstanding in this regard. *

I understand and agree

❖ I agree that Cosmikali Tattoo has a NO REFUND policy on tattoos, piercing and/or retail sales and I will not ask for a refund for any reason whatsoever. I understand that I am paying for her services, time, guidance, and expertise, which cannot be refunded. *

I understand and agree

❖ I agree to reimburse Cosmikali Tattoo and any associates for any attorneys' fees and costs incurred in any legal action I bring against them and in which either the Artist or her associates are the prevailing party. *

Yes

❖ I hereby declare that I am of legal age (and have provided valid proof of age and identification) and am competent to sign this Agreement. *

Yes

❖ I acknowledge that I have been given adequate opportunity to read and understand this document that it was not presented to me at the last minute and grasp that I am signing a legal contract waiving certain rights to recover damages against Cosmikali Tattoo also known as Gaia (legal name Gianna Michael). ❖ If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document. ❖ I HAVE READ THE AGREEMENT, I UNDERSTAND IT, AND I AGREE TO BE BOUND BY IT. *

I understand and agree

Electronic Signature *

Thank you for taking the time to fill out the consent form.

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