- Select tattooer - *ChooseAshley ThomasDesiree KeysAlejandro RamirezDonnie BrownUpload state issued ID *Choose FileNo file chosenDelete uploaded fileUpload stencil *Choose FileNo file chosenDelete uploaded fileFirst NameLast NameDateEmail AddressBirth DateDL NumberID - Issuing state *Expiration Date *PhoneStreet AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeCountry AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemen Arab Rep.Yemen DemocraticZambiaZimbabweAgreement 1AgreementHTMLI acknowledge that by signing this agreement that I have been given ample opportunity to ask any and all questions which I might have about the process of obtaining a tattoo and that all questions have been answered to my full satisfaction. I specifically acknowledge that I have been informed of the facts and matters outlined below and I agree as follows:Agreement *If I have any condition, medical or otherwise, that might affect the process of applying or healing this tattoo, I have advised my tattooer. I am not pregnant or nursing. I am not under the influence of alcohol or drugs.I do not have medical or skin conditions including but not limited to the following: acne, scarring (keloid), eczema, psoriasis, freckles, moles, or sunburn in the area to be tattooed that may interfere with said tattoo. If I have any type of infection or rash ANYWHERE on my body, I have advised my tattooer.I acknowledge it is not reasonably possible to for the representatives/employees of this tattoo shop to determine whether I may have an allergic reaction to pigments or processes used in my tattoo, and I agree and accept the risk that such a reaction is possible.I acknowledge that infection is always possible as a result of obtaining a tattoo, particularly in the event I do not take proper care of my tattoo. I have received aftercare instructions and I agree to follow them while my tattoo is healing. I agree that any touch up work needed will be done at my own expense, unless the tattooer decides otherwise.I realize that variations in the color and design may exist between the tattoo as selected by me and the tattoo as it is applied to my body. I understand that on darker skin tones inks may not appear as vividly as they do on lighter skin tones.I understand that if I have any skin treatments, laser hair removal, plastic surgery, or other skin altering procedures, it may result in aadverse changes to my tattoo.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 a physical, medical, or mental impairment or disability which might affect my well being as a direct or indirect result of my decision to have a tattoo.I acknowledge that I am over the age of 18 and have truthfully represented to my tattooer that the obtaining of a tattoo is by my choice alone. I consent to the application of the tattoo and to any actions of the representatives and employees of the tattoo shop reasonably necessary to perform the tattoo procedure.HTMLI have read the above information and understand that this is a legally binding document, and that by signing I agree to and am bound by its terms.Signature *Start signing your signature hereYour browser does not support e-Signature field.Name *Date Signed - Acknowledgement *Form SectionCompliance Header HTMLSALT LAKE COUNTY REASONABLE NOTIFICATION COMPLIANCE SECTIONCompliance Description - HTMLPlease answer Yes or No to all of the following questions and sign below. By signing this form you are acknowledging that you have been reasonably informed of the inherent risks involved in the tattoo processes and procedures in accordance with Salt Lake County law, and release Echelon Tattoo and Echelon Creative, Inc. from any and all responsibility associated with said processes and procedures. Article 4.2.5. sections iii-iv from Salt Lake Valley Health Department Body Art Facilities Regulation:a. Has your date of birth has been verified from a valid, government issued photo identification? *Yes or NoYesNob. Have you disclosed any known allergies to latex, iodine, or other products routinely used in a body art procedure? *Yes or NoYesNoc. Have you ingested blood thinners such as aspirin or ibuprofen within 24 hours prior to receiving a body art procedure? *Yes or NoYesNod. Have you consumed alcohol or other intoxicants within 24 hours prior to receiving a body art procedure? *Yes or NoYesNoe. Do you have a condition that might affect the procedure or healing process such as lupus, diabetes, or hemophilia, etc? *Yes or NoYesNo(iv) Are you aware of risks associated with body art procedures such as the risk of fainting, vomiting, and infection including bacterial endocarditis for patrons with a heart condition? *Yes or NoYesNoCompliance Signature *Start signing your signature hereYour browser does not support e-Signature field.Compliance Name *Compliance Date *Send MessagePlease do not fill in this field.