TATTOO CONSENT FORMDan Bone / Memoir Tattoo / 7377A Beverly Blvd, Los Angeles, CA 90036I specifically acknowledge that I have been advised of the facts and matters set forth below, and I agree as follows: Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### CONSENT TO APPLICATION OF TATTOO. RELEASE AND WAIVER OF ALL CLAIMS. * I acknowledge that I have been truthfully represented to the employees, agents and representatives of Memoir Tattoo, that I am over 18 (eighteen) years old. I acknowledge I am not pregnant. I acknowledge that I am free from communicable diseases. I also acknowledge that I am not ill, have a cold, or have any history of herpes infection at the proposed procedure site, diabetes, hemophilia or other bleeding disorder, or cardiac valve disease. I acknowledge that it is not reasonably possible for the representatives and employees of Memoir Tattoo to determine whether I might have an allergic reaction to the dyes, pigments, latex, petroleum based ointments or processes used in my tattoo, and I ag I acknowledge that tattoo inks, dyes, and pigments have not been approved by the Federal Food and Drug Administration and that the health consequences of using these products are unknown. I acknowledge that infections are always a possibility as a result of obtaining a tattoo, particularly in the event that I do not take proper care of my tattoo. I also understand that there is a possibility of scarring. I acknowledge receipt of the written instructions advising me of the proper care of my tattoo and I recognize the absolute necessity for following those instructions. I acknowledge that variation in color and design may exist between any tattoo selected by me and as ultimately applied to my body. I am NOT under the influence of alcohol or drugs and I am voluntarily submitting to be tattooed without duress or coercion. 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 my tattoo(s). I understand that if I choose to have the tattoo removed, it may be expensive and I acknowledge that the obtaining of my tattoo is by my choice alone and I consent to the application of the tattoo and to any actions or conduct of the employees of Memoir Tattoo, reasonably necessary to perform the tattoo procedure. I agree to to release and forever discharge and hold harmless, Memoir Tattoo, and its agents, employees, representatives, officers and shareholders from any and all claims, damages or legal actions arising from or connected in any way with my tattoo or pr I agree to give Memoir Tattoo, Dan Bones and their affiliates consent to publish any and all photos of my tattoo(s). I acknowledge by signing this form, that I have been given the full opportunity to ask any and all questions which I might have about the obtaining of a tattoo, from Dan Bones and/or the artists in resident at Memoir Tattoo; and all of my questions have been answered to my full and total satisfaction. * First Name Last Name Date * MM DD YYYY Thank you!