Release Form

Name(required)

Email(required)

Phone Number(required)

Date of Birth(required)

Drivers License / ID Number(required)

I acknowledge by signing this release form that I have been given the full opportunity to ask any and all questions I might have about obtaining a tattoo from WHITE BUFFALO GALERY. I acknowledge that all my questions have been answered to my full and total satisfaction. I specifically acknowledge that I have been advised of the facts and matters set forth below, and I agree as follows: (required)

I am not under the influence of alcohol or drugs.(required)

I do not have acne, freckles, moles, or sunburn in the area to be tattooed that might be agitated by the tattoo process (healing excluded).(required)

I have looked over my design, checked the spelling if applicable, and give my full consent to the application of my tattoo.(required)

I acknowledge that I am not pregnant.(required)

I acknowledge that I am free of communicable disease.(required)

I acknowledge that I have truthfully represented to the associates, agents and representatives of WHITE BUFFALO GALLERY that I am over eighteen (18) years of age.(required)

I acknowledge it is not reasonably possible for the associates, agents and representatives of WHITE BUFFALO GALLERY to determine whether I might have an allergic reaction to the dyes, pigments, or processes used in my tattoo and I agree to accept that such risks are possible.(required)

I acknowledge that infection is always possible as a result of obtaining a tattoo particularly in that event that I do not take proper care of my tattoo, and I have been advised of the signs and symptoms of infection that indicate a need to seek medical care.(required)

I acknowledge receipt of written instructions advising me of proper care of my tattoo and recognize the absolute necessity of following those written instructions. All questions about the body art procedure have been answered to my satisfaction.(required)

I acknowledge that variations in color and design may exist between any tattoos as selected by me and as ultimately applied to my body.(required)

I acknowledge that tattooing is a permanent change to my appearance and that no representations have been made to me as to the ability to later change, alter or remove my tattoo.(required)

I acknowledge that the obtaining of my tattoo is my choice alone and I consent to the application of the tattoo and to any actions or conduct of the associates, agents or representatives of WHITE BUFFALO GALLERY that are reasonable necessary to perform the tattoo procedure.(required)

I agree to release and forever discharge and forever hold harmless WHITE BUFFALO GALLERY and its associates, agents, officers and shareholders from any and all claims, damages, or legal actions arising from or connected in any way with my tattoo or the procedures and conduct used to apply my tattoo and any and all tattoos applied by WHITE BUFFALO GALLERY and its associates, agents and representatives in the future.(required)

I acknowledge that tattoo inks, dyes and pigments have not been approved by the federal Food and Drug Administration and the health consequences of using these products are unknown.(required)

I acknowledge that there is a chance I might feel lightheaded, dizzy during or after being tattooed. I agree to immediately notify the practitioner in the event I feel lightheaded, dizzy and/or faint before, during or after the procedure.(required)

I acknowledge the use of tegaderm or saniderm bandage and that there is the possibility of having an allergic reaction to the medical adhesive. I have discussed this with my artist.(required)

I agree to follow all instructions concerning the care of my tattoo, and that any touch-ups needed because of my own negligence will be done at my own expense. (required)

I have been fully informed of the risks of tattooing including but not limited to infection, scarring, difficulties in detecting melanoma, and allergic reactions to tattoo pigment, latex/nitrile gloves, saniderm/tegaderm medical adhesive bandage and antibiotics. Having been informed of the potential risks associated with getting a tattoo, I still wish to proceed with tattoo application and I assume any and all risks that may arise from tattooing. (required)

Do you have any of the following conditions: TB, HIV, HERPES, DIABETES, EPILEPSY, ASTHMA, HEPATITIS, HEMOPHILIA, BLEEDING DISORDER, PREGNANT, NURSING, SKIN CONDITIONS, BLOOD THINNERS, ECZEMA, PSORIASIS, HEART CONDITION, FAINTING, DIZZINESS, SCARRING, KELOIDING, GONORRHEA, SYPHILIS, MRSA, STAPH, ALLERGIC REACTIONS TO LATEX, ALLERGIC REACTIONS TO ANTIBIOTICS?(required)

Do you have any additional allergies such as to metals, soaps, cosmetics or alcohol?(required)

Yes No

Do you use any medications that might affect the healing of the body art you wish to receive?(required)

Yes No

Do you have any other medical or skin conditions that affect the outcome of your procedure?(required)

Yes No

Have you ever been prescribed antibiotics prior to dental or surgical procedures?(required)

Yes No

Do you have any cardiac valve disease?(required)

Yes No

Other medical conditions?(required)

Tattoo Artist(required)

Tattoo Description(required)

Location on Body(required)

Signature(required)

By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.(required)