COVID-19 Pandemic Tattoo Consent Form
Name*
First Name Last Name
Date*
Month Day Year
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Name of Tattooist for upcoming visit*
I knowingly and willingly consent to having tattoo service(s) during the COVID-19 pandemic.*
by checking this box I understand and accept this statement.
To prevent the spread of contagious viruses and to help protect each other, I understand that i will have to follow the tattoo shops strict guidelines*
by checking this box I understand and accept this statement.
I know that the CDC and OSHA recommend social distancing of at least 6 feet.*
by checking this box I understand and accept this statement.
I understand that due to the frequency of visits of other clients, the characteristics of the virus, and the characteristics of tattoo services, that I have elevated the risk of contracting the virus by merely being in the salon company.*
by checking this box I understand and accept this statement.
I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. Symptoms include: cough, shortness of breath, difficulty breathing, fever/chills, muscle/body aches, vomiting/diarrhea, new loss of taste or smell. Additionally new symptoms from the CDC include: persistent pain or pressure in chest, new confusion, inability to wake or stay awake, and bluish lips/face. If you have experienced Andy of these symptoms please call to reschedule immediately. It is impossible to determine precisely who has it, and who does not given the current limits in virus testing, but we are going above and beyond to ensure the virus doesn't touch our shop premises.*
by checking this box I understand and accept this statement.
All visitors entering Massachusetts, including returning residents, who do not meet an exemption, are required to: Complete the Massachusetts Travel Form prior to arrival, unless you are visiting from a lower-risk state designated by the Department of Public Health; Quarantine for 14 days or produce a negative Covid-19 test that has been administered up to 72 hours prior to your arrival in Massachusetts (If your Covid-19 test result has not been received prior to arrival, visitors and residents must quarantine until they receive a negative result);Verify that I have not traveled outside the United States in the past 14 days to countries that have been affected by Covid-19. I confirm that I have not traveled by commercial air, bus or train within the past 14 days*
YES NO
Tattoo Shop Symptoms Policy
I agree not to come to the Tattoo Shop with the following symptoms of COVID-19 listed below: Fever- Temperature Shortness of breath Loss of sense of taste or smell Dry cough Runny nose Sore throat
I am at least 18 years of age. I am not under the influence of drugs or alcohol. To the best of my knowledge, I do not have any contagious or communicable diseases of the blood or skin. I do not have any physical, mental, or medical conditions or disabilities, which might affect my well being as a direct or indirect result of my decision to have any tattoo related work done at this time. I hereby release SpeakEasy Galley from all manner of liabilities, claims, actions and demands, in law or in equity, which my heirs or I have or might have now or hereafter by reason of complying with my request to be tattooed. I agree not to sue or take any form of legal action whatsoever against SEG in connection with any and all damages based upon injuries or property damage to, or death of myself or any other persons arising from my decision to have tattoo related work done, whether or not caused by any negligence of SEG. I fully understand that SEG, when performing tattooing does not act in the capacity of a medical professional. The suggestions made by SEG are just suggestions, and are not to be construed as or substituted for advice from a medical professional. Being of sound mind and body, I do hereby release any and all persons representing SEG from all responsibility, holding SEG harmless from all damages, actions, cause of action, claim judgments, cost of litigation, attorney fees, and all other costs and expenses which might arise from my decision to have tattoo related work done. I agree to pay for any and all damages and injuries to any and all persons and property belonging to SEG or any other persons who may become liable contractually or by operation of lay, caused by, or resulting from my decision to have tattoo related work done by SEG. I accept any and all responsibility for myself for any consequences that might come from my decision to have tattoo work done by SEG at this time. I understand that I will be tattooed using the appropriate instruments, equipment, and techniques. To ensure proper healing of my new tattoo I agree to follow the aftercare instructions until the healing process is complete. I understand that if my skin pigment is dark, the colors will not appear as bright as they do on light skin. I agree that any touch up work needed, as a result of my own negligence will be done at my own expense. I agree to allow SEG to photograph this tattoo for any and all uses such as publication, advertisement, and all other personal uses. I have read & understand that there are no refunds on tattooing. I understand that my identity will remain confidential. I agree to leave the premises promptly upon request, for any reason whatsoever. I agree to these waivers also to pertain to and are designed to protect any and all establishments where SEG conducts business. By my signature below, I certify that I am at least 18 years of age. I willingly submit to their procedures with a full understanding of possible complications such as infection, allergic reaction, or fading. I have read and fully understand the above paragraphs. I represent and warrant SEG that all the following information is true and correct. I hereby assume full responsibility for the after care and cleanliness. I further understand that if I give false information or produce false documents stating my name and age to be other than correct, that I am liable for prosecution.*
by checking this box I understand and accept this statement.

COVID-19 Pandemic Tattoo Consent Form

Tattoo Shop Symptoms Policy