The Story Blossom Inc.

Consent, Liability and Safety Waiver

A Confidential Medical Screening

Please read the following questions and answer them to the best of knowledge. We askthat you inform your tattoo artist and/or studio manager of all possible concerns beforethey begin your session to ensure the safest experience while in our care.

Please review each statement below and then sign at the bottom of this form indicatingthat you understand and agree to the terms of receiving this procedure from the body artpractitioners of The Story Blossom Inc:

I am the person on the legal ID presented as proof that am at least 18 years of age.

I am not under the influence of alcohol or drugs.

I am voluntarily submitting to be tattooed without duress or coercion.

I understand there is a possibility of an allergic reaction and/or scarring.

I agree to follow all instructions concerning the care of my body art and that any touch upsdue to my negligence will be done at my own monetary expense.

I agree to immediately notify the artist in the event that feel lightheaded, dizzy or faint before, during or after the procedure.

I agree the payment for the tattoo or other service/purchase are non-refundable.

I agree to pay in full for the service.

I understand that this procedure involves the deposition of permanent ink into my skin and if I choose to have it removed, it may be expensive and leave scars.

I understand that tattoo inks, dyes and pigments have not been approved by the Federal Food and Drug Administration (FDA) and the health consequences of using these products.

I undersand that no guarantee has been made as to the results of this procedure and the final results may be different than they appeared on the day of my procedure. Pigments change and fade over time due to unique skin types, iron deficiency, sun exposure, etc.

I understand that there is difficulty in detecting melanoma and the body art partitioners of The Story Blossom Inc. may not know how the procedure will or affect my skin.

I have been informed on the risks of body art including and not limited to infection, scarring, difficulies in detecting melanoma and allergic reactions to tattoo pigments and antibiotics.

I understand the potential risks associated with this body art procedure and assume any and all risk that may arise from this procedure.

If elect to use a topical anesthetic prior to or during my session, I certify that am not allergic to Novocaine, Lidocaine, Tetracaine, Benzocaine, Triclosan or Epinephrine. I take full responsibility for any reaction resulting from the use of the topical anesthetics applied and waive and and all claimes against The Story Blossom Inc and or any of its practitioners to the fullest extent permitted by law.

I will keep my belongings/valuables attended during the entire session. The body art partitioners of The Story Blossom Inc/The Story Blossom Inc is not respoensible.

I grant permission for photos of my tattoo to be taken on today's date. I understand that photographs taken of my tattoo during this session may be used, wholly or in part, on the internet, in any publication, portfolio, or display, or in any other print or electronic medium as this body art partitioner chooses, I will make no monetary or other claim against this artist for use of the photographs. I understand that my name may or may not be included/credited in any form of publication unless requested otherwise.