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Authentic Images Tattoos & Piercings Consent Form <br /> In accordance with the city of Escalon ordinance on tattooing or piercing, the appropiate lines on this <br /> forms must be completed by the applicant. <br /> ALL ANSWERS MUST BE LEGIBLE. <br /> if consent to this Tattoo Piercing_ (check one) I consent that i an 18years of <br /> age or older. l have shown my valid I . D . and also acknowledge that Authentic Images Tattoos arld Piercing <br /> is not responsionsible for the care of the tattoo or piercing once I have left the facility I agree to keep the <br /> area clean and infection free . I will use normal hygiene and follow aftercare instructions to keep it clean <br /> and infection free. I acknowledge that the Artist is using sterile equipment to do the tattoo or piercing. <br /> Answer the follo ving Health History Questions. YES or NO: <br /> RE YOU PREGNANT? <br /> f JAUNDICE OR HEPATITIS ? �NANCE IO AMighic� <br /> ALLEGIES TO : LATEX? PIGMENTS/DYES ? _ ANT DIES''?_ <br /> SKIN DISEASE OR SKIN CANCER? _ <br /> vbIABETES? <br /> SKIN SENSIVITY TO SOAPS OR DISINFECTATNTS? _ <br /> EPYLEPSY, SEIZURES , FAITING, OR NARCOLEPSY? <br /> ' TAKING MEDICATIONS , BLOOD THINNERS ? _ <br /> HISTORY OF COMMUNICABLE DISEASE? <br /> 'HISTORY OF HEMOPHILIA OR BLEEDING DISORDER_ <br /> /CARDIAC VALVE DISEASE <br /> Do you require antibiotics before surgery or dental procedures ? <br /> History of Herpes Infection on procedure area?_ <br /> It is normal to expected redness , tenderness and even some <br /> swelling in the procedure area(s) <br /> Print first and last name: Date of Birth <br /> Print Adiess: STREET CITY STATE ZIP <br /> I CERTIFY THAT THE ABOVE STATED INFORMATION IS TRUE TO THE BEST OF MY <br /> KNOWLEDGE. <br /> CLIENT SIGNATURE DATE <br /> W <br /> PIERCING MINOR CONSENT 2 <br /> I am the natural parent or legal gardian al': W <br /> 2 <br /> (Print name of minor) 0 <br /> Dlinors date of birds : — <br /> Minois age: 0 <br /> I have the legal authority to give consent to the body piercing ol' this child. 0 <br /> location: 2 <br /> ll <br /> signature of Parent/Le al Guardian W <br /> g Body Piercing-Prohibits anyone U <br /> from performing or offering to J <br /> ARTIST/PIERCER ONLY perform a piercing upon anyone d <br /> BIRTH CERTIFICATES: under age 18 unless the <br /> PARENT/GARDIAN ID: piercing Is performed in the <br /> CHILD SCHOOL ID: presence of a parent or <br /> guardian or as directed and <br /> notarized by the minor's parent <br /> or guardian. Does not apply to <br /> emancipated minors and does <br /> not Include pierces or the ear. <br /> NEEDLE(S) USED : <br /> LOT #: <br />