COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

BODY ART CLIENT INFORMED CONSENT FORM CLIENT INFORMATION Name: Age: Date of Birth: Phone: Address: Email: Emergency contact: Phone: PROCEDURE INFORMATION INFORMED CONSENT Read and initial the boxes below to confirm the Tattoo information is understood I am the person on the legal ID presented as Procedure Site: proof that I am at least 18 years of age. Type of ID: Description of Procedure: I am under the age of 18 years old and have the presence of my parent or guardian to receive the body piercing. (Applicable only to MEDICAL HISTORY underage body piercing. NIA if not applicable). Circle an conditions listed below that a Iv to vou I am not under the influence of alcohol or drugs TB Asthma Antibiotic Allergies Hemophilia and that I am voluntarily submitting myself to HIV Hepatitis Cardiac Valve Scarring/ receive body art without duress or coercion. Disease Keloiding I understand the permanent nature of receiving Epilepsy Skin Pregnant/ MRSA/Staph body art and that removal can be expensive Conditions Nursing Infections Iand may leave scars on the procedure site. Diabetes Blood Fainting/ Latex Allergies The body art described or shown on the Thinners Dizziness consent form is correctly placed to my specifications. All questions about the body art procedure have When was the last time you ate: been answered to my satisfaction, and I have been given written aftercare instructions for the Do you have any additional allergies to metals, soaps, procedure I am about to receive. cosmetics, alcohol? I understand the restrictions on physical o you use any medication that might affect the healing activities such as bathing, recreational water D the body art? activities, gardening, contact with animals, and of the durations of the restrictions. History of herpes infection on the procedure site? I understand there is a possibility of getting an infection and I am aware of the signs and Other Bleeding Disorders? symptoms, including, but not limited to redness, Current Medications swelling,tenderness of the procedure site, red streaks going from the procedure site towards Other risk factors for blood borne pathogens? the heart, elevated body temperature, or purulent drainage from the procedure site. Other medical conditions? If I experience signs and symptoms of infection I will Any allergies to shellfish? seek medical attention. I understand that there is a chance I might feel Do you require Antibiotics prior to surgery lightheaded, dizzy during or after being or dental procedures? tattooed. I will notify the artist immediately if this occurs. NOTICE:TATTOO INKS:Tattoo inks,dyes, and pigments that have not been approved by the Federal Food and Drug Administration have health consequences that are unknown. I acknowledge that the information that I have provided is true to the best of my knowledge. I have been fully informed of the potential risk associated with a body art procedure. I still wish to proceed with the body art application, and 1 assume any and all risks that may arise from body art.Aftercare has been explained and instructions have been provided. ❑ Aftercare Instructions were reviewed and provided Printed Client Name: Signature of Client: Date: Name of Practitioner: Body Art Facility Name: I have reviewed the client's information that was presented and have provided information on aftercare. All information provided by the client is correct, to the best of my knowledge. Practitioner Signature: Date: