CONSENT TO TATTOO PROCEDURE

Do you have any allergies?*

If so please list all allergies below:

Details:

Are you pregnant or nursing?*

Do you have any medical conditions or contagious diseases that may affect your tattoo procedure?*

If so please check all applicable conditions below:

N/A

Diabetes

HIV/AIDS

Eczema?Psoriasis

R.I.S.

Epilepy

Hemophilia

Infections

Fainting

T.B.

Scarring/Keloiding

Seizures

Hepatitis

Heart Conditions

Narcolepsy

Blood Thinners

I acknowledge by signing this consent form that I have been given the full opportunity to ask any and all questions I might have about obtaining a tattoo from Solemn Heart Studio. I acknowledge that all my questions have been answered to my full and total satisfaction. I specifically acknowledge that I have been advised of the facts and matters set forth below.

I agree as follows:

I am not under the influence of Alcohol or Drugs.

I acknowledge that I do not have any acne, freckles, moles, or sunburn in the area to be tattooed that might be agitated by the tattoo process (Healing Excluded)

I acknowledge that it is not reasonably possible for the associates, agents and representatives of Solemn Heart Studio to determine whether I might have an allergic reaction to the dyes, pigments, or processes used in my tattoo and agree to accept that such risks are possible.

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

I agree to follow all instructions concerning the care of my tattoo, and that any touch-ups needed because of my own negligence will be done at my own expense.

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, alter or remove my tattoo.

I acknowledge that the obtaining of my tattoo is my choice alone and I consent to the application of the tattoo and to any actions or conduct of the associates, agents, or representatives of Solemn Heart Studio that are necessary to preform the tattoo procedure.

I acknowledge that I have no physical, mental or medical impairment or disability that may affect my well being as a direct or indirect result of my decision to get a tattoo.

I understand that skin treatments, laser hair removal, plastic surgery, exposure to sunlight, or another skin altering procedure may result in adverse changes to my tattoo.

I acknowledge that I have truthfully represented to the associates, agents and representatives of Solemn Heart Studio that I am over (18) years of age.

I acknowledge that the correct spelling/characters for any words or phrases in any language are my responsibility, not the artists and I have checked prior to application.

Disclosure Statement

Clients of tattoo establishments should be aware that although the tattoo establishment complies with all rules of sanitation and sterilization, it is still possible that Bloodborne disease or infection could be a contracted as a result of a tattoo procedure.

I, the stated client of Solemn Heart, have read and understood the above foregoing "Disclosure Statement" and acknowledge the possible effects or consequences.

NOTICE FOR FILING A COMPLAINT

Any person with personal knowledge or information about a violation of the Body Piercing and Tattooing Rules may file a complaint in writing to the Oklahoma State Department of Health, Consumer Protection Division, 1000 NE 10th Street, Oklahoma City, OK 73117-1299.