I acknowledge that I am not pregnant and that I am free of communicable diseases. *

I Agree

Please indicate (by checking the box) if any of the following conditions apply to you: *

Heart Disease

Keloiding

Diabetes

Heavy Bleeding

Epilepsy

HIV/AIDS

Cold Sores - HPV

Hepatitis

NONE of these

I acknowledge that I am not under the influence of any drugs or alcohol. *

I Agree

I acknowledge that I have truthfully represented to SocialGracesTattooStudioLLC that I am over 18 years old, or I am over 16 years old and my parental guardian is present with me in this process. *

I Agree

I acknowledge that it is not reasonably possible for SocialGracesTattooStudioLLC to determine whether I might have an allergic reaction to the dyes, pigments, jewelry or processes used in my modification, and I agree to accept the fact that such a risk is possible. *

I Agree

I acknowledge that infection is always possible as a result of the obtaining of any modification, particularly in the event that I do not take proper care of my modification. *

I Agree

I acknowledge receipt of verbal or written instructions advising me of the proper care of my modification and I recognize the absolute necessity for following those instructions. *

I Agree

I acknowledge that a modification is a permanent change to my appearance and that no representation has been made to me as to the ability to restore my body to its original state. *

I Agree

I acknowledge that the obtaining of my modification is by my choice alone and I consent to the application of the modification and to any actions or conduct by SocialGracesTattooStudioLLC reasonably necessary to perform the procedure. *

I Agree

I agree to release and forever discharge and hold harmless SocialGracesTattooStudioLLC of any and all claims, damages, or problems I may have there after receiving my modification. *

I Agree

I hereby give SocialGracesTattooStudioLLC the rights to do as they wish with pictures that may be taken of the modification I am receiving. *

I Agree

I understand that after I leave SocialGracesTattooStudioLLC the modification is my responsibility. *

I Agree

Name *

First Name

Last Name

Birthday *

If under 18, legal guardian approval is needed. (you will still need to provide an ID to proceed.)

MM

DD

YYYY

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country