Release Form Consent for the application of a tattoo Release and waiver of all claims Tattoos are PERMANENT!! Removal is a surgical procedure that can cause scarring and disfigurement.* 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 at this time. * 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 keloiding. * I acknowledge that I have truthfully represented to the employees, agents and representatives of Basilica Tattoo that I am over 18 (eighteen) 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 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 anyway with my tattoo or procedures and conducted 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. * *If an adverse reaction or infection develops at the site of your tattoo, contact your personal physician for treatment and report to SNHD Special Programs at (702) 759-0677. Name* First Middle Initial Last Date of Birth* Date Format: MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican 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 RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican 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 RicoQatarRéunionRomaniaRussiaRwandaSaint 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 IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone*Phone Carrier*3 River WirelessACS WirelessAlaska CommunicationsAlltelAmeritechAT&TBell (Canada)BellSouthBlue Sky FrogBluegrass CellularBoost MobileBPL MobileCaroline West WirelessCellcomCellular OneCellular SouthCentennial WirelessCenturyTelClearnetCleartalk WirelessComcastCorr Wireless CommunicationsCricketDobsonEdge WirelessFidoGolden TelcomGoogle FiHelioHouston CellularIllinois Valley CellularInland Cellular TelephoneKoodo MobileMCIMetro PCSMetrocallMicrocellMidwest WirelessMobilcommMTSNextelnTelosOnlineBeepPCS OnePresident's ChoicePublic Service CellularQwestRogers AT&T WirelessRogers CanadaSatellinkSolo MobileSouthwestern BellSpectrumSprintStraight TalkSumcomSurewest CommunicationsTeleflipTelusT-MobileTracfoneTritonUnicelUS CellularUS WestVerizonViaero WirelessVirgin MobileVirgin Mobile CanadaWest Central WirelessWestern WirelessWind MobileXfinity MobileXIT CommunicationsEmail Address* Email Reminders?*YesNoTattoo Design*Placement*Artist Name* Vic Vivid Hiram Casas Jose Carlos Dayan Masu How did you hear about us?*FacebookInstagramGoogleYelpFriendOtherDate* Date Format: MM slash DD slash YYYY Signature* This iframe contains the logic required to handle Ajax powered Gravity Forms.