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BODY ART CONSENT FORM <br /> CLIENT INFO INFORMED CONSENT TO RECEIVE BODY ART <br /> PLEASEMDAND CHECK THE BMTS WHEN yDUARE CFMAIN YOU <br /> Name: Date: UNDEASTAND7HEIMPI.YATWNSOFSIGNINO <br /> Address: In consideration of recewing BODY ART from, <br /> wsau,e.a+•+1 <br /> Phone number. Date of girth: . the practitioner at (together with its Employees, <br /> aYrpaY,MruYol <br /> /F: dE • apprentices,and agents,the•SodyArt Business") <br /> Erhall <br /> I confirm thafollowing b`/Initialing each applicable item: <br /> ErnergencY[antXr Phone: Imy� <br /> Type oflden[7lmtton provided: ?Tpttpalnla,dyer,wW pigmeaa OW have notlrecn apPwwdby <br /> tMhderdFaodandOngAdMnODaNmshave health consequences that Om <br /> Ortvem License passport Birth CerdAate unknown. <br /> _I am the perspo an the legal ID presented as Pmafthat l am at least <br /> Apply a check to the type ofboO ortbehWer/ormad' tg years ofaget. <br /> Permanent _I am underthe age of a years aid and have the presence of my <br /> Tattoo Banding Piercing pxrentorguardlan to receive the body piercing.(Applicable onlyto <br /> cosmetics Branding <br /> bodypserclm.N/Ad ran applicable). <br /> _I am not under the influence of alcohol or drugs and that I am <br /> Procedure Sore: D cdpdonafPmmdure: voluntarily submitting myself to race"body art without duress or coercion. <br /> _I acknowledge that the information that I have provided In the <br /> medial quesdonnalre is complete and me tithe best of my knowledge. <br /> I understand the permanent nature of receiving body an and that <br /> removal on be eaperdwe and may lave scars on the procedu re site. <br /> _The body an described orshawn on the client record form Is <br /> correctly placed to mytpeclBatl6m. <br /> MEDICAL HISTORY _All questions about the body art procedure have been ansWared to <br /> my sathfeelon,and I have been given written aftercare Imtr udomforthe <br /> please drde nuffstEdbeAawttaityg AM MO. procedure l amaboutto receive. <br /> I understand the re mictloru on physical aNvides'sueh as bathing, <br /> TB Asthma Eaema/Psortasis Gonorrhea recreational water acdvltl.,gardening,contact with animals,and the <br /> durations of the restrictions. <br /> HIV Hepatitis Heart Conditions Syphilis _I understand that any medial Information obtained will be subject to <br /> the federal"With Imurance Portability and Accountability Act al 1996 <br /> �BtentH ursing hlRSW <br /> Skin ydKtionth (HIPPA). <br /> Herpes [anditians <br /> _9 am aware that tattoo Inks,dyes,and pigments used on the <br /> Diabetes Blood Falnting/Dbainesc latex Allergies procedure aka haw not been approued by the federal Food and Drug <br /> l <br /> Antibiotic AdMnklation,aid that the health wmequ, a s;of using these products <br /> Epllepry HemaphRla Sarting/geldding Allergies areunlmown. <br /> I am aware tithe signs and symptoms of infection,Including,but not <br /> km_ed kto redness,swelling,tenderness of the procedure she,red streaks <br /> How bog has it been since you last alai going from the procedure site e towards the heart,elevated body <br /> temperature,or purulent drainage from the procedure site. <br /> _I understand there is a possibility afgetdng an Infection asa result of <br /> Do you have any additional allergies such as to metals,snaps,cosmetics or receiving body art particularly In the event that l do not take proper are of <br /> alcohol theproa lumsite. <br /> 1 will seek professional medal attention Ifslans and symptoms of <br /> Do you use any mediations that might affect the healing of the body artyou Infection occur. <br /> with to receive? _I agree to fallow all in nuttlorss concerning the are of mytatrou, <br /> and tiwt any Muewps needed due to my awn negligence will be done at my <br /> Do you have a hict"of herpes at the procedure site? own expense. <br /> I understand that there Is a chance I might feel lightheaded,dizzy <br /> Do you have any other medical or skin mndltlo0 that affeutheoutmmeot during or~bdng tattooed. <br /> yot r proadure? _I agree to Immediately notdythe amstln the event l feet <br /> lightheaded,diary and/or hint before,during or afar the procedure. <br /> Have you ever been presented anublotka prior to dental or surgical 4 Issantrame/hays been fully <br /> procedures? Informed of bar risAF ofbody art iMumro but not Bruited to ahfettO4 <br /> Da you hen anyordlacvalve disease? scarring,dlJfleuldes in detectingmakirmM and otkryk reaction to tallow <br /> pill m 4lam,gbws,andaMbtotka.Having been Informed of the potential <br /> riskeduM <br /> SM <br /> d with <br /> H there any Information you feel you should Provide to the WdY art body artapplassociated`Wth ndImume body art ac'yMW Nriskth tMay( IMNI'lhe <br /> dxiyortapplkoRan ondlassumeanYondoRfhla tlmtmaYpdieffam 6tdy i <br /> pactitloner? oft. <br /> other medaal conditluns? sputure of Cgerrb Dace: <br /> GP `{ ,CL- Or Syr {S S' Sfasstum oFPnNdwrer: . <br /> t3 Q isi Pa�F4w ,w ss 'r b\ rr% a s/is/v <br />