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Informed Consent for Permanent Cosmetics or Tattooing <br /> PLEASE READ AND INITIAL THE BOXES WHEN YOU ARE CERTAIN YOU <br /> UNDERSTAND THE IMPLICATIONS OF SIGNING <br /> In consideration of receiving a tattoo from the practitioner at <br /> Name of the Practitioner <br /> (together with its employees, apprentices, and agents, the"Tattoo Business" <br /> Name of Tattoo Business <br /> I confirm the following: <br /> —All questions about the body art procedure have been answered to my satisfaction, and I have been <br /> given written aftercare instructions for the tattoo I am about to receive. <br /> The tattoo described or shown on the Client record form is correctly drawn to my specifications. <br /> _I understand that tattooing is permanent and that if I choose to have it removed, it may be expensive <br /> and leave scars. <br /> I am the person on the legal ID presented as proof that I am at least 18 years of age. <br /> _I am not under the influence of alcohol or drugs and that I am voluntarily submitting to <br /> to be tattooed without duress or coercion. <br /> _I understand there is a possibility of an allergic reaction to the inks and pigments commonly <br /> used in tattooing. <br /> _I understand that Tattoo inks, dyes and pigments have not been approved by the federal Food and <br /> Drug Administration and that the health consequences of using these products are unknown. <br /> I understand there is a possibility of getting an infection, and I have been advised of the signs <br /> and symptoms of infection that indicate a need to seek medical attention. <br /> I agree to follow all instructions concerning the care of my tattoo, and that any touch-ups <br /> needed because of my own negligence will be done at my own expense. <br /> I understand that there is a chance I might feel lightheaded/dizzy during or after being tattooed. <br /> _I agree to immediately notify the practitioner in the event I feel lightheaded, dizzy, and/or faint <br /> before, during or after the procedure. <br /> I, have been fully informed of the risks of tattooing <br /> including but not limited to infection, scarring, difficulties in detecting melanoma, and allergic reactions to <br /> tattoo pigment, latex gloves, and antibiotics. Having been informed of the potential risks associated with <br /> getting a tattoo, I still wish to proceed with tattoo application and I assume any and all risks that may arise <br /> from tattooing. <br /> Signed Date <br /> Permanent Cosmetics and Tattooing Page 3 of 3 <br />