Declaration of Consent

Personal Details

Please answer the following questions truthfully. Incorrect information can lead tomedical risks. Where medical and personal problems exist, or chronic diseases, or where pharmaceuticals/medications are being taken, we reserve the right to refuse to carry out the piercing.

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Did you have an appointment or did you use our walk-in? AppointmenbtWalk-In Which of our studios are you in? CharlottenburgTempelhof Do you already have a piercing? YesNo [group zeig-mehr-gepierct] If yes, which piercings? [/group] [group nichts-mehr-gepierct][/group] Did you have any problems with them? YesNo [group zeig-mehr-probleme] If yes, which problems? [/group] [group nichts-mehr-probleme][/group] Do you have high/low blood pressure? YesNo Do you take any blood-thinning medication? YesNo [group zeig-mehr-blutveruennende] If yes, which one. how much, and when did you last take it? (e.g. Aspirin, ASS, Heparin Plavix, Xarelto etc.) [/group] [group nichts-mehr-blutveruennende][/group] Have you eaten and have you had sufficient to drink? YesNo Do you work out? YesNo [group zeig-mehr-sport] If yes, what kind of sports? [/group] [group nichts-mehr-sport][/group] Did you drink alcohol yesterday? YesNo [group zeig-mehr-alkohol] If yes, how much? [/group] [group nichts-mehr-alkohol][/group] Do you have an increased tendency to bleed? YesNo Are you a haemophiliac? YesNo [group zeig-mehr-bluter] If yes, how high is your INR ratio? [/group] [group nichts-mehr-bluter][/group] Are you diabetic? YesNo Do you have any skin diseases? YesNo Do you have any allergies or intolerances? YesNo [group zeig-mehr-allergien] If yes, which ones? [/group] [group nichts-mehr-allergien][/group] Do you have an allergy pass? YesNo Do you have scar tissue that hasn't healed smoothly? YesNo Do you have scar tissue that hasn't healed smoothly? YesNo [group zeig-mehr-wildfleischblutung] If yes, where? [/group] [group nichts-mehr-wildfleischblutung][/group] Do vou have circulatory problems? YesNo Do you regularly take prescrition drugs/medication? YesNo [group zeig-mehr-medikamente] If yes, which ones? [/group] [group nichts-mehr-medikamente][/group] Did you have to take antibiotics within the last 2 weeks? YesNo [group zeig-mehr-antibiotika] If yes, what kind and why? [/group] [group nichts-mehr-antibiotika][/group] Will you under go surgery within the next few weeks? YesNo [group zeig-mehr-operiert] If yes, why? [/group] [group nichts-mehr-operiert][/group] Are you epileptic or do you have epileptic seizures? YesNo [group zeig-mehr-epileptiker] If yes, which ones? [/group] [group nichts-mehr-epileptiker][/group] Do you have Hepatitis C., HIV or aTV infection? YesNo [group zeig-mehr-Hepatitis] If yes, which one? [/group] [group nichts-mehr-Hepatitis][/group] Do you have any STDs? YesNo [group zeig-mehr-Geschlechtskrankheiten] If yes, which one? [/group] [group nichts-mehr-Geschlechtskrankheiten][/group] Are you pregnant or do you plan to get pregnant soon? YesNo Do you have a baby and breastfeed? YesNo Do you have any holiday plans in the next few weeks? YesNo

Possible Complications

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Even following correctly applied piercings, there is a risk of the following side effects:

  I have read and understood Yes

Necessary Signatures

Thereby declare my consent to a piercing

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All my questions about my desired tattoo were answered and the process explained in detail.The tattoo is according to §223 Abs. 1 StGB an intervention in the physical integrity and thus a bodily injury. By my signature under this declaration of consent, I expressly agree to the tattoo and it does not apply to the illegality of bodily injury.I was informed that Autark - das Tattoostudio in Deutschland.® with the placing of order is not in any liability position. Should it come to legal measures - on whatever basis - the freelancer (tattoo artist, piercer, etc.) is exclusively liable. With my signature I assure that all information is true.

I have read and understood Ja Date Signature of client

Still a minor? When you are still a minor, this declaration of consent has to be signed by a legal guardian.The signature of the legal guardian serves as confirmation. With the signature, the legal guardian allows the aforementioned treatment/process and confirms that the data and information stated in thisdeclaration are correct.

First name, Last name, Street, Nr. (of legal guardian) Date Signature of legal guardian

We wil take photographs of the completed work.The customer hereby explicitly agrees that these photographs may be used for purposes beyond those permitted by Art. 6paragraph 1() EU DSGVO for the purpose of external presentation on our website, on our social media channels or on advertising banners. In addition, we will collect health data in this declaration of consent so that we can decide whether the execution of the contract si possible without endangering your health and without impairing the result of our work. Therefore without these data collection t h econtract will not be carried out by us. These data are special data according to Art. 9 EU DSGVO. Herewith, you give your express consent to the collection of said data.We will not pass on these data to third parties, and they will be stored by us for a period of 10 years. Afterwards, the declarations of consent will be deleted. This consent can be revoked at any time (Art. 7 para. 3 EU DSGVO). After the revocation, we are not allowed to use and process the photographs collected and/or used with the consent. The health data collectedwill be kept until t h eend of the retention period, as it is legitimate to process them until the time of revocation.

Date Your information will be forwarded to Autark Tattoo Studio, who will contact you via email around your tattoo or piercing appointment. Signature of client

Piercing Information

(to be filled in by the studio)

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Details/placementof piercing Inserted jewellery Date of piercing Follow-up care appointments Name of piercer

Is the client eligible for the piercing?

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Some piercings require specific physical conditions to be met. This has been checked by the piercer i na preliminaryexamination.

Is the piercing anatomically possible? YesNo Date Signature of piercer

If no, why was it refused?