Mercy Seat Consent Form Consent Form Your Info First Name Last Name Address Address Address Address Address Address Address Address Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Email Date of Birth Phone Please check all to acknowledge I do not have medical or skin conditions such as but not limited to: acne, scarring (Keloid) eczema, psoriasis, freckles, moles or sunburn in the area to be tattooed that may interfere with said tattoo. If I have any type of infection or rash anywhere on my body, I will advise my tattooer. I acknowledge it is not reasonably possible for the representatives and employees of Mercy Seat Tattoo to determine whether I might have an allergic reaction to the pigments or processes used in my tattoo, and I agree to accept the risk that such a reaction is possible. I acknowledge that infection is always possible as a result of the obtaining of a tattoo, particularly in the event that I do not take proper care of my tattoo. I have received aftercare instructions and I agree to follow them while my tattoo is healing. Download Aftercare Instructions I agree that any touch-up work needed, due to my own negligence and will be done at my own expense. I realize that variations in color and design may exist between any tattoo as selected by me and as ultimately applied to my body. I understand that if my skin color is dark, the colors will not appear as bright as they do on light skin. I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my tattoo. I acknowledge that a tattoo is a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove my tattoo. To my knowledge, I do not have a physical, mental or medical impairment or disability which might affect my well being as a direct or indirect result of my decision to have a tattoo. I acknowledge I am over the age of eighteen and that I have truthfully represented to my tattooer that the obtaining of a tattoo is by my choice alone. I consent to the application of the tattoo and to any actions or conduct of the representatives and employees of the tattoo shop reasonably necessary to perform the tattoo procedure. I understand that tattoo(s) are created by hand and the appearance of the artwork will differ from the tattooed procedure. I agree to release and forever discharge and hold harmless Mercy Seat Tattoo and all its independant contractors from any and all claims, damages, and legal actions arising from or connected in any way with my tattoo and the procedures and conduct used to apply my tattoo. I am not a hemophiliac (bleeder). I do not have epilepsy, hepatitis, HIV, AIDS, or any communicable disease. I am not under the influence of alcohol and/or drugs. I am not pregnant or nursing. If I have any condition that might affect the healing of this tattoo, I will advise my tattooer. I acknowledge that the artists are not translators and cannot guarantee the spelling or meaning of foreign words or symbols. I confirm that the spelling of any words to be used for the tattoo are correct and to my liking. I agree to allow any photographs taken by the artist to be used for media advertising such as but not limited to; social media outlets, newspaper, commercials, tv, flyer ads, website, portfolio displays, other marketing materials, etc. I agree to be put on Mercy Seat Tattoo newsletter mailing list. (Note: by giving us your email address you give us permission to contact you. You can opt out at any time by using the opt-out link in the newsletter.) I knowingly and willingly consent to being tattooed during the COVID 19 pandemic. I understand the COVID 19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. I release Mercy Seat Tattoo and all affiliates from any responsibility should I catch COVID 19 as it is nearly impossible to pinpoint where infection occurred given our current state of lack of tests and mass testing. I certify that I am not presenting any symptoms of COVID 19 including fever, shortness of breath, loss of taste or smell, dry cough, runny nose, sore throat. I verify that I have not been sick in the last 14 days and I have not been around anyone who has been sick in the last 14 days. Signature * Clear Drivers License Pic Drop a pic of your license here or click to upload Choose Pic Maximum upload size: 10MB Submit If you are human, leave this field blank.