Waiver

Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Farenheit? *

Yes No

Have you or anyone in your household been tested for COVID-19? *

Yes No

Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days? *

Yes No

Have you or anyone in your household traveled in the U.S. in the past 21 days? *

Yes No

Have you or anyone in your household traveled outside the U.S. in the past 21 days? *

Yes No

Are you or anyone in your household a health care provier or emergency responder? *

Yes No

Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive postive or has tested positive for COVID-19? *

Yes No

Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19? *

Yes No

To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19? *

Yes No

WAIVER, RELEASE, AND CONSENT TO TATTOO

In consideration of receiving a tattoo from

Artist Name *

and Gnostic Tattoo, LLC (and its employees, apprentices and agents), I agree to the following:

I hereby declare that I am of legal age (and have provided valid proof of age) and am competent to sign this Agreement.
I HAVE READ THIS AGREEMENT, I UNDERSTAND IT, I AGREE TO BE BOUND BY IT.

PHOTO ID (you can take a picture of it with your phone) *

Max file size: 20MB

Address *

Line 1

Line 2

City

State

Zip Code

Country

HEALTH QUESTIONAIRE

​WAIVER, RELEASE, AND CONSENT TO TATTOO

WAIVER, RELEASE, AND CONSENT TO TATTOO