I confirm that I am not experiencing any symptoms of illness including fever, excessive coughing/sneezing, sore throat, rash, infection, etc.

This field is required.

I hereby, attest I am at least 18 years old and do not have any physical, mental, or medical impairment or disability, including allergies which might affect my well being as a direct or indirect result of my decision to have any tattoo/piercing related work performed on me. I accept any and all responsibility for any consequences for my decision to have any tattoo/piercing related work, including spelling, numerals, & design. I authorize my tattoo artist to design my body art request via his or her interpretation. I agree to pay for any and all damages or injuries to any and all persons and property resulting from my decision to have any tattoo/piercing related work done by a representative of Black Squirrel Tattoo. I hereby release any and all persons representing Black Squirrel Tattoo from all responsibility, now and in perpetuity. I have also received aftercare instructions for my tattoo/piercing and agree to follow all instructions concerning care while it is healing.

I have read and understand the above information. I represent and warrant that the above information is true and correct.