Ref No.: [Submission Reference]
Date: [Submission Date]

I, [Field 3] [Field 4], having email [Field 5] hereby consent to and authorize The Art of Ink located at 123 Creative Lane, Metropolis, ST 12345 to perform tattooing/piercing. I acknowledge that any permanency or subsequent changes that might result are my responsibility. I confirm that I have disclosed any relevant medical conditions that might affect the procedure.

Appointment Date: [Field 7]

Contact Number: [Field 6]

Terms & Conditions:

1. I acknowledge that tattoos and piercings are permanent. 
2. I have reviewed the aftercare instructions and understand the importance of following them.
3. I release The Art of Ink from any and all liability related to the procedure.
4. I have read this waiver and agree to the terms of service.