Hold Harmless Agreement

First name

Last Name

Phone Number

Date of Birth

Govt Issued ID#

Address Line 1

Address Line 2

City

State/Province

Zip/Postal Code

Country

As a person 18 years of age and older, I hereby freely give my consent to Urban Element Tattoo to perform all necessary procedures for the placement of a tattoo on my body.*

I affirm that I do not have any of the following: A heart condition, epilepsy, diabetes, a communicable disease, skin diseases/lesions, am not prone to seizures or fainting, narcolepsy, or currently taking blood thinning medications, nor have I had hepatitis within the last year. Further, I affirm I am not a hemophilic and am not under the influence of drugs and/or alcohol.*

To my knowledge, I do not have any medical or mental impairment or disability that might affect my well-being as a direct or indirect result of my decision to have any tattoo and/or piercing procedure done at this time.*

I agree to follow all instructions concerning the care of my tattoo and/or piercing while it is healing. The artist and Urban Element Tattoo, LLC have given me instructions on the care of my tattoo while it is healing and I understand and will follow them.*

I acknowledge it is possible the tattoo can become infected, particularly if I do not follow the aftercare instructions provided to me. I will consult a physician at the first sign of an adverse reaction (swelling, infection, illness, allergic reaction, disease etc.) If any touch-up work is needed because of my negligence, I agree that the work will be done at my expense.*

I understand if my skin color is dark, the colors will not appear as bright as the do on lighter skin. Additionally, I understand the finished tattoo may vary somewhat in appearance, color, and/or design from the paper or other drawing/photographic image that the tattoo design is based on. I understand that over time, the colors and the clarity of my tattoo will fade from unprotected exposure to the sun and the naturally occurring dispersion of pigment under the skin.*

I acknowledge it is not reasonably possible for the representatives and employees of Urban Element Tattoo, LLC to determine whether I might have an allergic reaction to the pigments or process used in my tattoo, and I agree to accept the risk that such a reaction is possible.*

I understand that if I have any skin treatments, laser hair removal, plastic surgery, or other skin altering procedures, it may result in adverse changes to my tattoo.*

Being of sound mind and body, I hereby release Urban Element Tattoo, LLC, and all employees, agents, or persons representing Urban Element Tattoo, LLC from all responsibility with respect to my tattoo/piercing related work.*

I agree to not sue Urban Element Tattoo, LLC or employees, agents, or persons representing it in connection with any and all damages to or death of myself or any other persons arising from my decision to have any tattoo and/or piercing related work at this time, whether or not caused by any negligence of Urban Element Tattoo, LLC employees or agents.*

I agree for myself, my heirs, assigns and legal representatives to hold harmless from all damages, actions, causes of action, claim judgments, costs of litigations, attorney's fees and all other costs and expenses that might arise from my decision to have any tattoo and/or piercing work done by Urban Element Tattoo LLC.*

I have been advised that the tattoo will be permanent and that it can only be removed with a surgical procedure, and that any effective removal will leave permanent scarring and disfigurement. This cautionary notice is required to be provided to me by the health department and I hereby acknowledge receipt of this formal notice.*

I agree to pay for any and all damages and injuries to any persons and property belonging to Urban Element Tattoo, LLC or any other person to whom they may become liable contractually or by operation of law, caused by or resulting from my decision to have any tattoo and/or piercing work by Urban Element Tattoo, LLC.*

I hereby grant irrevocable consent to and authorize the use of any reproduction by Urban Element Tattoo, LLC, and any and all photographs which are taken this day of me, negative or positive proof which will be hereby attached for any purposes whatsoever, without further compensation to me. All negatives, together with the prints, video, or live internet stream shall become and remain the property of Urban Element Tattoo LLC, solely and completely.*

I swear or affirm and agree that the above information is true and correct. I have been provided with information describing the tattoo and/or procedures to be performed and instructions on aftercare. I have been made aware that if I have any signs or symptoms of infection, such as swelling, pan, redness, warmth, fever, unusual discharge or odor to contact my physician. It is also my responsibility to take care of my new tattoo and/or piercing site according to the instructions provided both verbally and in writing.*

Description of tattoo (Please be specific)

Tattoo location on body (Please be specific)

Front of Govt Issued ID

Take Photo

Please take a picture of the front of your ID

Back of Govt Issued ID

Take Photo

Please take a picture of the back of your ID

I declare that the info I have provided is accurate and complete.*

Your Signature*

Hold Harmless Agreement

Urban Element Tattoo

Contact Us |