COVID-19 RELEASE FORM QUESTIONS

    I Understand - To prevent the spread of contagious viruses and to help protect others, I understand that I will have to follow the facility's guidelines. The facility’s guidelines can be changed at anytime as new information and technology become available

    I Confirm - that I am not presenting any of the symptoms of COVID-19 including

    • • dry cough

    • • runny nose

    • • sore throat

    • • shortness of breath

    • • loss of sense of taste or smell

    • • fever

    I Confirm - that I have not been in close contact with anyone with these symptoms or anyone who has been diagnosed with COVID-19 in the past 14 days.

    What to Know Before Getting a Tattoo

    While a tattoo may only take a few minutes to acquire, it is permanent. You should understand the risks and research the process before getting a tattoo. Tattooing involves breaking the skin, one of your body's main protective barriers. This means you may be more susceptible to skin and blood infections. Specific risks include:

    Bloodborne disease: If the equipment used to do your tattoo is contaminated with the blood of an infected person, you can contract a number of serious bloodborne diseases. These include, hepatitis C, hepatitis B, tetanus and HIV, the virus that causes AIDS.
    Skin infection: The use of unsterile equipment or re-used ink can result in skin infections, ranging from minor to potentially serious antibiotic resistant infections. Symptoms may include redness, swelling or pus-like drainage.
    Granulomas: Bumps may form around the site of the tattoo as a reaction to the ink.
    Scars and keloids: The ink may cause scars and keloids (raised, ridged areas caused by overgrowth of scar tissue)
    Allergic reactions: The ink may cause an itchy rash at the tattoo site.
    Swelling or burning: Tattooed areas may swell or burn during Magnetic resonance imaging (MRI) exams.

    Additional topics to discuss with your body art professional include their Bloodborne Pathogen Training, the establishment’s proficiency requirements, and the establishment’s autoclave monthly spore test results.

    If abnormal itching, irritation, redness, swelling or fever should appear, please contact a physician immediately. These could be signs of potentially serious medical condition that should be addressed.

    To ensure that your body art procedure heals properly, we ask that you disclose if you have or have had any of the following conditions. Disclosure does not legally prevent you from having a body art procedure.

    *Diabetes
    YesNo
    *History of hemophilia (Bleeding)
    YesNo
    *History of skin diseases, skin lesions, or skin sensitivities to soaps, disinfectants, etc.
    YesNo
    *History of allergies or adverse reactions to pigments, dyes or other skin sensitivities such as latex
    YesNo
    *History of epilepsy, seizures, fainting or narcolepsy
    YesNo
    *Use of medications, such as anticoagulants that thin the blood and/or interfere with blood clotting
    YesNo
    *Human immunodeficiency virus (HIV)
    YesNo
    *Hepatitis
    YesNo

    Are you currently pregnant
    YesNoN/A

    *I give UpRise Tattoo permission to take photos and post them online.
    YesNo

    *First Name:

    *Last Name:

    *Client Phone:

    *Client Email:

    *By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic
    signature is the legal equivalent of your manual/handwritten signature on this Agreement.
    I Accept

    Congrats you finish filling up the form, now let us finish filling up the rest to complete your form.

    *Date:

    Artist:

    *Client Picture ID: