The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is reported to be extremely contagious. The state of medical knowledge is evolving, but the virus is believed to spread from person-to-person contact and/or by contact with contaminated surfaces and objects, and even possibly in the air. People reportedly can be infected and show no symptoms and therefore spread the disease. The exact methods of spread and contraction are unknown, and there is no known treatment, cure, or vaccine for COVID-19. Evidence has shown that COVID-19 can cause serious and potentially life threatening illness and even death.
As with any invasive procedure, tattooing may involve possible health risks. These risks may include pain, bleeding, swelling, infection, or scaring of the area and nerve damage. Non-sterile equipment and needles can spread infectious disease; it is extremely important to us that all equipment is clean and sterile before use. Tattoos are not easily removed and in some cases can cause permanent discoloration, with the possibility of an allergic reaction. Blood donations cannot be made for a year after getting a tattoo. The body art practitioner will properly cleanse the area before the procedure, use sterilized equipment, employ universal precautions, and provide information on the aftercare of the area being tattooed.
- Have you been in close contact or cared for someone with a confirmed case of Coronavirus in the last 30 days? *Yes___ No___
- Are you currently living with anyone who is sick or quarantined *Yes___ No___
- Have you traveled on an airplane in or outside of the US in the last 30 days? *Yes___ No___
- Have you been on a cruise in the last 30 days? *Yes___ No___
- Have you been in close contact with anyone who has traveled in or outside of the US in the last 30 days? *Yes___ No___
- Are you currently experiencing or have you experienced any of the listed symptoms within the last 30 day’s including (cough, shortness of breath, fever, sore throat, respiratory illness, fatigue)? *Yes___ No___
- Are you currently experiencing or have you experienced any of the listed symptoms within the last 30 days including (Chills, shaking, muscle pain, headache, loss of taste or smell)? *Yes___ No___
- Do you have any allergies? *Yes___ No___(If yes, please circle all that apply). Antibiotics, Latex, Soaps, Metals, Cosmetics, Alcohol, Adhesives, Petroleum, Lidocaine, Lanolin oil, Shellfish, Other:_____________________________________
- Do you Have: (circle all that apply) Hepatitis. Tuberculosis. Gonorrhea. Syphilis. HIV/AIDS. Herpes. Staph
- Are you Pregnant? *Yes___ No___
- Do you have a history of any of the following? *Yes___ No__(please circle all that apply) Heart Disease, High Blood Pressure, Hemophilia, Psoriasis, Eczema, Epilepsy, Seizures, Narcolepsy, Fainting, Diabetes
- Auto-immunity? *Yes___ No___ If yes, list:__________________________________
- Do you have asthma? *Yes___ No___
- Do you currently have any infections? *Yes___ No__ If yes,list:______________________
- Are you prone to faintness? *Yes___ No___
- Do you have any skin disease / rash? *Yes___ No___
- Are you prone to scarring / keloiding *Yes___ No___
- Are you Taking any medication, prescription, or non-prescription such as anti-coagulants (coumadin, aspirin, ect.) ? *Yes___ No___
- Are you on any other medications? *Yes___ No___ If yes, list:_____________________________________________________________________
The following conditions may increase health risks associated with getting a tattoo and at the artist’s discretion may require a Dr.’s note to perform the tattoo:-Diabetes, -Hemophilia (excessive bleeding), – Skin disease, Lesions, or skin sensitivities to soaps, disinfectants, ect., – History of allergies or adverse reactions to pigments or dyes, -History of epilepsy, seizures, fainting or narcolepsy, -Use of anticoagulants, (such as coumadin or aspirin, ect.) which could thin the blood and /or interfere with proper clotting, -Hepatitis, or HIV infection.
- I acknowledge it is not reasonably possible for the representatives and employees of this tattoo shop 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 reaction is possible.
- I realize that variations in color and design may exist between any tattoo as selected by me, and as ultimately applied to my body. I understand that if my skin color is dark, the colors will not appear as bright as they do on lighter skin.
- I understand if i have any skin treatments, laser hair removal, plastic surgery, or other skin altering procedures, it may result in adverse changes to my tat the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.
- I acknowledge that Crown of Thorns Tattoo has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.
- I acknowledge that Crown of Thorns Tattoo can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, studio staff, and other studio clients and their families.
- I voluntarily seek services provided by Crown of Thorns Tattoo and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment. By submitting I hereby confirm that the information I have given above is true to the best of my knowledge. I understand my personal information will be kept confidential.
WAIVER OF LAWSUIT/LIABILITY: I have carefully read and fully understand all provisions of this release. I hereby forever release and waive my right to bring suit against Crown of Thorns Tattoo and its owners, officers, directors, managers, officials, trustees, agents, employees, or other representatives in connection with exposure, infection, and/or spread of COVID-19 related to utilizing Crown of Thorns Tattoo’s services and premises. I understand that this waiver means I give up my right to bring any claims including for personal injuries, death, disease or property losses, or any other loss, including but not limited to claims of negligence and give up any claim I may have to seek damages, whether known or unknown, foreseen or unforeseen.
CHOICE OF LAW: I understand and agree that the law of the State of Massachusetts will apply to this contract.
-I acknowledge that i am over the age of 18 and i have truthfully represented that the obtaining of a tattoo is my choice alone. I do not have a condition that prevents me from getting a tattoo. I consent to the application of the tattoo and to any actions or conduct of the representatives and employees of the tattoo shop necessary to perform the tattoo procedure. I also understand the studio has the right to refuse service to any clients at anytime, for any reason if they feel there is a risk involved.
DATE OF BIRTH_____________AGE________
LOCATION & BRIEF DESCRIPTION OF TATTOO____________________________________________
EMERGENCY CONTACT _____________________________PHONE________________________