Release Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 3Select Tattooer *ChooseAshley ThomasDesiree KeysLexx Jiménez-CorpPayton HuynhBrandon EdgecombJeni JolleyAlexis MedelShan GiesekeCherry JaneCeci LiToad CoatesGuest ArtistUpload state issued ID * Click or drag a file to this area to upload. Upload stencil * Click or drag a file to this area to upload. Name *FirstLastBirth Date *Date of BirthDL NumberDrivers License NumberID - Issuing StateIssuing StateExpiration DateExpiration date for State Issued IDPhoneAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeNextAgreementI 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:AgreementIf 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.I have let my artist know about any birth control implant or any other medical implant device I may have, and have appropriate medical clearance to receive a tattoo procedure, and/or accept full responsibility for any repercussions/consequences that may come from said procedure.I 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 *Clear SignatureAgreement SignatureName *FirstLastDate Signed *NextSalt Lake County Compliance FormPlease 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? *YesNob. Have you disclosed any known allergies to latex, iodine, or other products routinely used in a body art procedure? *YesNoc. Have you ingested blood thinners such as aspirin or ibuprofen within 24 hours prior to receiving a body art procedure? *YesNod. Have you consumed alcohol or other intoxicants within 24 hours prior to receiving a body art procedure? *YesNoe. Do you have a condition that might affect the procedure or healing process such as lupus, diabetes, or hemophilia, etc? *YesNo(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? *YesNoSignature *Clear SignatureName *FirstLastDate Signed *Submit
