SR0083901_3/8/2022 - Laserfiche WebLink

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PLEA5E REAb ANQ CHECK THE BOXES WHEN YOU ARE CERTAIN YOU UNQERSTANQ THE IMPLICATIONS OP SIGNING THIS DOCUMENT In consideration of receiving atattoo/permanent make-up from (Name of Practitioner), at (Name of Business), 1 confirm the following: -_i am not pregnant, I do not have a history of herpes Infection at the proposed procedure site, diabetes, allergic reactions to latex or antibiotics, hemophilia or other bleeding disorder, or cardiac valve disease. „_ I do not have a history of medication use or am currently using medication, including being prescribed antibiotics prior to dental or surgical procedures. _ All questions about the body art procedure have been answered to my satisfaction, and I have been given written aftercare Instructions for the tattoo I am about to receive. _, The tattoo described or shown on the Client record form Is correctly drawn to my specifications. _ I understand that tattooing is permanent and that if I choose to have It removed, it may be expensive and leave scars, _ i am the person on the legal ID presented as proof that I am at least 18 years of age. _ I am not under the influence of alcohol or drugs and that I am voluntarily submitting to be tattooed without duress or coercion, i understand there is a possibility of an allergic reaction to the Inks and pigments commonly used in tattooing, _ I understand there is a possibility of getting an infection, and I have been advised of the signs and symptoms of infection that indicate a need to seek medical attention. ,_ I agree to follow all instructions concerning the care of my tattoo, and that any touch-ups needed because of my own negligence will be done at my own expense. _, I understand that there is a chance I might feel lightheaded, dizzy during or after being tattooed, I agree to immediately notify the practitioner In the event i feel lightheaded, dizzy and/or faint before, during or after the procedure. have been fully informed of the risks of tattooing/permanent make-up including but not limited to risk factors for bloodborne pathogen exposure, infection and other medical complications, allergic reactions to metal Jewelry, latex gloves, and antibiotics, Having been informed of the potential risks associated with receiving a tattoo/permanent make-up, and I still wish to proceed with the procedure. I assume any and all risks that may arise from the tattoo/permanent make-up. Date