Date *

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DD

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Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Phone *

Country

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I permit Jameeley Pineda (aka Lakan Ubaya Nagsalad) to tattoo the location named above and in consideration of doing so, I release Jameeley Pineda from all manner of liabilities, claims, actions and demands, in law and equity, which I or my heirs have or might have now or hereafter by reason of complying with my request to be tattooed, I fully understand that Jameeley Pineda, when performing body modifications is not providing a medical service nor advice. *

I understand

I understand I will be tattooed using appropriate instruments and techniques, and I acknowledge that infection is always possible as a result of obtaining a tattoo. To ensure proper healing of my tattoo, I agree to follow the “aftercare instructions” pamphlet which I have received, read, and fully understand, until healing is complete. *

I understand

I understand that this type of modification usually takes 2-4 weeks or longer to heal. I willingly submit to these procedures with full understanding of possible complications such as, but not limited to; infection, allergic reaction, or bodily rejection of the tattoo. *

I understand

The following conditions may increase health risks associated with receiving body art: *

Diabetes, Epilepsy, Hemophilia, Heart conditions, Blood-thinning medications

I have informed the artist if I have any of these conditions.

Tattoo Procedures carry risk of transmitting blood borne pathogens, including the following:

HIV, Hepatitis

I have informed the artist if I have any of these conditions.

I do not wish to disclose.

By checking all below, I certify that I have read and agreed to each point. *

I know that if I have had a herpetic outbreak, the immune stress of receiving a tattoo may result in a herpetic outbreak.

I do not have a mitral valve prolapse or any other conditions that requires antibiotics before a medical procedure.

I have informed the artist if I have a known allergy to metals, pigments, latex, soaps or medications.

I certify that I am over 18 years of age.

I certify that I am not under the influence of drugs or alcohol that prevent me from consenting to a tattoo..

I acknowledge that obtaining a tattoo is my choice alone and will result in permanent change to my appearance.

I have eaten in the last four hours.

As with any invasive procedure, tattooing may involve health risks. These health risks may include: pain, bleeding, swelling, infection, scarring of the area, and nerve damage. Unsterile equipment and needles can spread infectious diseases; it is extremely important to be sure all equipment is clean and sanitary before use. The body art practitioner should properly and thoroughly cleanse the area before the procedure, use sterile equipment, use sterile techniques, and provide information on the aftercare of the area receiving body art. You may not be allowed to donate blood after temporarily or permanently. *

I have read and understood this disclosure statement.