This form is only for scheduled appointments.

Drunken Monkey Tattoo

(989) 497-0053

Reminder: We are CASH only. If needing to use other methods, there may be fees if available.

First name

Last name

Phone

Birthday

Month

Day

Year

Address

Do you have any allergies?

Conditions ? Diseases

Medications

Are you pregnant

Are you breastfeeding?

Emergency contact name and phone

Select an artist

Date of service

Location on body

Tattoo design

Have you applied any products, creams, ointments, or topical solutions to the tattoo area?

Agreements

Please select the check box of each item to agree

TO WAIVE AND RELEASE to the fullest extent premitted by law each of the Artist and the Tattoo Studio from all liability whatsoever, for any and all claimsof causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise, including and direct and/or consequential damages which result or arise from the application of my tattoo.

That both the Artist and the Tattoo Studio have given me the full opprotunity to ask any and all questions about the application of my tattoo and all of my questions have been answered to my total satisfaction.

I have recieved instructions on the care of my tattoo while it's healing, and I understand them 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 due to my own negligence, I agree that the work will be done at my own expense.

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 do not have or have notified my artist of diabetes, epilepsy, hemophilia, a heart condition, nor do I take blood thinning medication. I do not have or have notified my artist of any other medical or skin condition that may interfere with the 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 preventive regimen of antibiotics that is required by my doctor in advance of any invasive procedures such as tattooing.

I do not have a mental impairment that may affect my judgement in getting the tattoo

Neither the Artist nor the Tattoo Studio is responsible for the meaning or spelling of the symbol or text that I have provided to them or chosen, I have approved all work.

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 pigments 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 agree to reimburse each Artist and/or Tattoo Studio for any attorneys' fees and cost incurred in any legal action I bring against either the Artist or the Tattoo Studio and in which either Artist or the Tattoo Studio and in which either the Artist or the Tattoo Studio are prevailing party.

I agree that the courts of Michigan in Saginaw county shall have personal jurisdiction and venue over me and shall have exclusive jurisdiction for the purpose of litigating any dipute arising out of or related to the agreement

I have been given adequate opprotunity to read and understand this document, that it was presented to me prior to any procedure has taken place or started.

I release all rights to any photographs taken of me and the tattoo and give consent in advance to their reproduction in print or electronic form. (if you do not initial this provision, please advise your Artist and the Tattoo Studio NOT to take any pictures of you and your completed tattoo). Drunken Monkey Tattoo can use any photo taken of your tattoo on me by them - not limited to advertisement

Terms & Conditions

I hereby release and discharge Drunken Monkey and its employees from any type of negligence, liability, claim, action, demand, and compensation in law and in equity, which I have or might have, now and hereafter; by reason of my request to be tattooed/pierced. I also specifically release and forever discharge Drunken Monkey and its employees and its agents, for any and all loss or damage on account of injury to my person or property caused by Drunken Monkey otherwise; by reason of my request to be tattooed/pierced. I give permission to copyright and/or publish photographs of myself with or without my name in any such manner as deemed proper to their use. I realize that misrepresentation or falsification of information provided by me is a crime and is subject by prosecution. I further certify that I am over the age of eighteen and am not intoxicated or under the influence of any narcotic substance and made this statement entirely of free will and sound mind. If I am under the age of 18, my parent/legal guardian signs consent to release the same agreements. I acknowledge that a tattoo/piercing 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/piercing. I acknowledge it is not reasonably possible for the representatives and employees of this tattoo/piercing shop to determine whether I might have an allergic reaction to the pigments or processes used in my tattoo/piercing, and I agree to accept the risk that such a reaction is possible. I acknowledge that infection is always possible as a result of the obtaining of a tattoo/piercing, particularly in the event that I do not take proper care of my tattoo/piercing. I acknowledge that I have recieved aftercare instruction for my tattoo/piercing today. I undertsand that I am responsible for all the content in the tattoo to be accurate. This is a legal binding contract.

I have read agree to all Terms & Conditions

Touch Up Policy

Touch ups may only be free within 90 days after work is recieved, but ONLY if aftercare products that are recommended Drunken Monket Tattoo are purchased at time of tattoo, or at the artist discretion. No touch ups on fingers, hands, feet, toes, anything on head/face, elbows, knees, or cover-ups - along with anything else your artist may discuss - as these types of tattoos usually require second or multiplepasses to ensure work. Scar covers are excluded.

Do you plan to purchase aftercare from Drunken Monkey Tattoo?

Yes

What soap product do you plan to use

Note: Soap must be MILD, and fragrance free. Dial is NOT a mild soap and is no longer recommended.

What aftercare product do you plan to use

Note: Vaseline (petroleum jelly), most lotions (unless specific for healing and approved), neosporin or any triple antibiotic ointments are NOT recommended for healing this tattoo.

State Consent

I acknowledge that I have been offered a copy of the Disclosure Statement and Notice for Filing Complaints, that I will receive a copy of the Aftercare Information Sheet to the email address provided and that it was made available to me at the shop, and completed the Client Health Questionnaire and received any additional, applicable information. In addition, this record serves as signed documentation that the body art facility performing your tattoo, piercing, and/or branding is a licensed facility by the State of Michigan. It is recommended that individuals or organizations visit www.michigan.gov/bodyart to determine current the license status of the body art facility before proceeding with any body art procedure.

I acknowledge State Consent

Vaild Photo ID (limit 4 items)

Signature

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