By submitting this form I am confirming that I have read and understand all of the following information, and have provided the most accurate information to the best of my knowledge.

• I am not under the influence of Drugs or Alcohol.

• I am at least 18 years of age.

• I am not pregnant or nursing.

• I have reviewed my design, confirmed the spelling of the text (if applicable), and now grant full consent to receive this tattoo.

• I am voluntarily choosing to receive this tattoo of my own decision free of duress and/or coercion.

• I am free of communicable diseases to the best of my knowledge.

• I acknowledge that it is not reasonably possible for Sophia, StickyPoking, to determine whether or not I will have an allergic reaction to the ink, pigments, or process used during my appointment, and accept that those risks are possible.

• I acknowledge that by getting a tattoo and in the possible event that I do not properly take care of my tattoo, there is always a risk of infection and that I have been advised of what signs to look for that would indicate needing medical attention.

• I acknowledge the necessity of following all aftercare instructions for my tattoo, and that all questions I have regarding this tattoo have been answered adequately.

• I agree to release and forever discharge Sophia, StickyPoking, from any and all claims, damages, or legal actions that arise from or are connected in any way to my tattoo or the procedure of receiving my tattoo.

• I acknowledge that tattoos are permanent by nature and that the removal process can be costly and may leave scars.

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

• I acknowledge feeling faint or dizzy during or after the tattoo procedure is a possibility, and that in the event I become faint or dizzy before, during, or after the procedure that I will promptly notify my artist.