I, (Name of Patron) ___________________, hereby give consent to any artist of LUXME DEVI to perform a tattoo, and in consideration of doing so, I hereby release any artist of LUXME DEVI LA and LUXME DEVI LA from all manner of liabilities, claims, actions and demands in law, or in equity, which I or my heirs might now or hereafter by reason of complying with my request of a tattoo.

I fully understand that any employee of LUXME DEVI LA, when performing a tattoo, does not act in the capacity as a medical professional. The suggestions made by any employee or agent of LUXME DEVI LA are just suggestions. They are not to be construed as, or substituted for advice from a medical professional. I understand that the tattoo will be performed using appropriate techniques, instruments, and pigments. I also understand that infections can occur due to lack of proper hygiene and/or pigment sensitivities. To ensure proper healing of my tattoo, I agree to follow the written and verbal aftercare instructions that will be provided, until healing is complete. I understand that the healing process of a tattoo may take several weeks to heal properly.

I understand that I am making a permanent change to my body, and no claims about the possibility of reversing these changes have been made or implied by LUXME DEVI LA or any of its employees or agents.

Please answer the following questions:

Answering yes to any of these questions does not necessarily preclude the person from receiving a tattoo.

YES NO

Has a physician told you that you have hepatitis? _____ _____
Have you been jaundice (yellowing of skin or eyes) in the last 10 days? _____ _____
Are you prone to fainting? _____ _____
Do you have diabetes? _____ _____
Do you have difficulty-stopping bleeding? _____ _____
Do you take a blood thinner? _____ _____
Do you have heart related problems? _____ _____
Do you have high blood pressure? _____ _____
Do you have any known allergies? _____ _____

If so, please list them: ____________________________________________________

____________________________________________________

Have you consumed any alcoholic beverages within the last 8 hours? _____ _____
Have you consumed any food in the last 2 hours? _____ _____
Have you consumed any anticoagulants (aspirin, ibuprofen, etc.)

in the last 24 hours? _____ _____

Are you pregnant? _____ _____
Do you have any other health conditions that might affect the healing of _____ _____

this tattoo?

I have read this release form and confirm that all the information given is correct. I understand that this is a release form and

I agree to be legally bound by it.

Therefore, I authorize the tattoo artist to tattoo my _____________________. I understand that this type of tattooing takes 2 weeks or longer to heal. I agree to release and forever discharge and hold harmless any tattoo artist of LUXME DEVI LA and all employees of LUXME DEVI LA from any and all claims, damages, or legal actions arising from or connected in any way with my tattooing, or the procedure and conduct used in my tattooing.

By signing this release, I swear that under the penalty of perjury that I am at least 18 years old and understand that I am receiving a tattoo from a licensed tattoo artist in accordance with all state laws, rules and regulations.

I certify that I am over 18 years of age. Date of birth:______________________________________

Your name ___________________________ Telephone (_____)_______________________

Address _____________________________ City, State and Zip _______________________________

Signature:

Today’s date:

Sak Yant Integration Questionnaire