Consent to Tattoo Procedure Release and Waiver of All Claims -Wiscosin
DEPARTMENT OF HEALTH SERVICES
Division of Public Health
STATE OF WISCONSIN
Bureau of Environmental and Occupational Health
CONSENT TO TATTOO PROCEDURE
RELEASE AND WAIVER OF ALL CLAIMS
Operators are required by DHS 173.10 (2) to collect certain personally identifiable information for the purpose of determining procedural
eligibility. Completion of this form is not required by statutory reference. Services will not be provided without the completion of this
I acknowledge by signing this Release that I have been given full opportunity to ask any and all questions that I
might have about obtaining a tattoo and that all my questions have been answered to my full satisfaction. I
specifically acknowledge that I have been advised of the facts and matters set forth below and I agree as
1) If I have diabetes, epilepsy, hepatitis, hemophilia, HIV-AIDS or any other communicable disease, heart
condition or I take medication that thins the blood, I have advised my tattooer. I am not pregnant or
nursing. I am not under the influence of alcohol or drugs.
2) I do not have medical skin conditions such as, but not limited to: acne, scarring (keloid), eczema,
psoriasis, freckles, moles or sunburn in the area to be tattooed that may interfere with my tattoo.
3) I acknowledge it is not reasonably possible for the employees of ________________________ to
determine if I might have an allergic reaction to the pigments or processes used in my tattoo, and I agree
to accept the risk that such a reaction is possible.
4) I acknowledge that infection is always possible as a result of obtaining a tattoo, particularly in the event
that I do not take proper care of my tattoo. I have received aftercare suggestions and agree to care for my
tattoo to the best of my ability.
5) 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 is dark, the colors will not appear as bright as
they do on light skin. I understand that a tattoo is a work of art and minor imperfections are likely.
6) 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.
7) 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. To my knowledge, I do not have
any physical, mental or medical impairment or disability that might affect my well being as a direct or
indirect result of my decision to have a tattoo.
8) I have truthfully represented to _______________________________ that I am at least 18 years of age
and that obtaining a tattoo is by my choice alone.
Therefore, I request the application of a tattoo. I agree to release and forever discharge and hold harmless
____________________________, and all employees from any and all claims, damages or legal actions arising
from or connected in any way to my tattoo or the procedure and conduct used in the application of my tattoo.
Name – Print legibly
SIGNATURE - Patron
Address City State Zip
Date of Birth
Name of Practitioner (print legibly)
SIGNATURE - Practitioner
Consent to Tattoo Procedure Release and Waiver of All Claims -Wiscosin PDF
Favor this template? Just fancy it by voting!
7 Page(s) | 2487 Views | 2 Downloads
1 Page(s) | 1748 Views | 36 Downloads
1 Page(s) | 939 Views | 6 Downloads
1 Page(s) | 614 Views | 3 Downloads
2 Page(s) | 1401 Views | 14 Downloads