Consent Form "*" indicates required fields * First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*I acknowledge I am NOT pregnant and I am not nursing at this time.* I acknowledge that I am not under the influence of alcohol or drugs on the date of my tattoo appointment.* I am free from all communicable diseases. I do not have: Epilepsy, Jaundice, Hepatitis, AIDS/HIV or Hemophilia. I will let my artist know if I have issues with scarring or keloids.* I acknowledge that I have truthfully represented to the employees, agents and representatives of Basilica Tattoo that I am over 18 years old with proper identification.* I acknowledge that it is not reasonably possible for the representatives and employees of Basilica Tattoo to determine whether I may have an allergic reaction to the dyes, pigments or processes used in my tattoo, and I agree to accept that this risk is a possibility.* I acknowledge that infections are always a possibility as a result of obtaining a tattoo, particularly in the event that I do not properly take care of my tattoo.* I acknowledge receipt of the written instructions (found on https://www.basilicatattoo.com/healing/ ) advising me of the proper care of the tattoo and I recognize the absolute necessity for following those instructions and I agree that any touch-up work needed due to my own negligence will be done at my own expense.* I acknowledge that variation in color and design may exist between any tattoo selected by me and as ultimately applied to my body.* 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(s).* I acknowledge that the obtaining of my tattoo is by my choice alone and I consent to the application of the tattoo and to any actions or conduct of the employees of Basilica Tattoo, reasonably necessary to perform the tattoo procedure.* I agree to release and forever discharge and hold harmless Basilica Tattoo and its agents, employees, representatives, officers and shareholders from any and all claims, damages or legal actions arising from or connected in any way with my tattoo procedures and conduct used to apply my tattoo.* I agree to give Basilica Tattoo consent to publish any and all photos of my tattoo(s).* I acknowledge that all payments, both deposits and payments for services the day of the appointment, are non-refundable.* To my knowledge, I do not have any physical, mental or medical impairment or disability which might affect my well-being as a direct or indirect result of my decision to have a tattoo.* UPLOAD YOUR DRIVERS LICENSE* Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, pdf, Max. file size: 10 MB, Max. files: 1. 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