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Elusive Pu & Tattoo NT BODY ART CONSEFORM CLIENT INFO ' INFORMED CONSEW TO RECEIVE BODY ART PLEASE RTAD AND CHECK 7W BOXES WHEN YOU AR£CERTAIN YOU Name: Date: UVDERSTAND THE M&PIICATIONSOFSIGNING Address: In considerermn of receiving BODY ART from, w,.mns employees,Phone number: Date of Birth: the practitioner at (together with its employees, rs.m<mme,ua,ssl Email: apprentices,and agents,the"Body Art Business") Emergenry contact Phone I =firm the following by hdtlaling each applicable kem: : d>ar.,v.q Type of Identificorian Provided: NOTI[E':Tattoo inks,dyes,ondpigments that have nebeen approved by the federal Food and Drug Administration have health consequences that are Drivers License Passport Birth Certificate unknown Apply a check to the type of body an being perfomred: I am the person on the legal ID presented as proof that I am at least 18 years of age. Tattoo Permanent cosmetics I am not under the Influence of alcohol or drugs and that I am Procedure Site: Description of Procedure: voluntarily submitting myself to receive body an without duress or coercion. _I acknowledge that the information that 1 have provided in the medical questionnaire is complete and true to the best of my knowledge. _I understand the permanent nature of receiving body an and that removal can be expensive and may leave scars on the procedure site. _The body art described or shown on the client record form is correctly placed to my specifications. MEDICAL HISTORY _All questions about the body an procedure have been answered to my satisfaction,and I have been given written aftercare instructions for the Please drcle any conditions listed below that a 1 In you. _ procedure I am about to receive. I understand the restrictions on physical activities such as bathing, TB Asthma EctemafPsorlash Gonorrhea recrcaHoral water activities,gardening,contact with animals,and the durations of the restrictions. HIV Hepatitis Heart Conditions Syphilis l understand that any medical information obtained will be subject to Skin MRSA/Staph the federal Health Insurance Portability,and Accountability Act of 1996 Herpes Conditions Pregnant/Nursing Infections (HIPPA). eloatl 'I am aware that tattoo inks,dyes,and pigments used on the Diabetes Thinners Fainting/Dizziness Latex Allergies procedure site have not been approved by the federal Food and Drug Antibiotic Administration,and that the health consequences of using these products Epilepsy HNm2halia Srarring(KNalding Allergies are unknown. _I am aware of the signs and symptoms of infection,Including,but not limited to redness,swelling,tenderness of the procedure site,red streaks How long has it been since you last ate? going from the procedure site towards the heart,elevated body temperature,or purulent drainage from the procedure site. I understand there Is a possibility of getting an Infection as a result of Do you have any additional allergies such as to metals,soaps,cosmetics or receiving body an particularly In the event that I do not take proper care of alcohol? the procedure site. Curtent merfamfions —1 will seek professional medical attention if signs and symptoms of infection occur. _I agree to follow all instructlans concerning the are of my tattoo, and that any touch-ups needed due to my awn negligence will be done at my Do you have a history of herpes at the procedure site? own expense. _I understand that there Is a chance I might feel lightheaded,dizzy Do you have any other medical or skin conditions that affect the outcome of during or after being tattooed. your procedure? I agree to Immediately notify the artist In the event I feel I Ightheaded,dizzy and/or faint before,during or after the procedure. Have you ever been prescribed andblotkcs prior to dental or surgical procedures? 11 (print name)have been fully informed oftherisks ofbodyart including but not limited to infection. Do you have any cardiac valve disease? scorring,ci f Iculdes In detecting melanoma,and allergic react/ons to tattoo pigment,later gloves,and an iblatics.Having been informed of the potential Is there any Information you feel you should provide to the body an risks associated with o body an procedure,I still wish to proceed with the practitioner? body an application and I assume any and all risks that may arise from body art. Other medical conditions? Signature of Client: Date: Signature of Practitioner: Date: