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VISUAL CHANGES TATTOO SHOP <br /> =- <br /> CONSENT ANIS QUESTIONNAIRE FORM <br /> 445 w Webber Ave, <br /> Stockton, CA 95203 <br /> CLIENT QUESTIONNAIRE AND CONSENT FORM FOR BODY ART <br /> Before a body art procedure begins, the body artist shall obtain pertinent records and an informed consent from <br /> the client. This information shall be obtained in a Client Questionnaire and Consent Form. <br /> A Client Questionnaire and Consent Form may include a client records forni; medical history questionnaire and <br /> informed consent form to perform body art and will be considered confidential information. All information <br /> gathered from the client that is personal medical information and that is subject to the federal Health Insurance <br /> Portability and Accountability Act of 1996 (HIPPA) or similar state laws shall be maintained or disposed of in <br /> compliance with those provisions. <br /> The shop permit holder is obligated to maintain proper records for each customer. The records shall include the <br /> following: <br /> 1. The date of the procedure. <br /> 2. Record of information on a picture identification showing name, age and current address of client. <br /> 3. The description of the procedure. This includes the design and location of the tattoo, permanent <br /> cosmetics,branding, or body piercing. <br /> 4. The name and registration number of the tattooist, permanent cosmetic technician, branding, or <br /> body piercer. <br /> 5. Copy of the signed Client Questionnaire and Consent Form to perform the tattoo, permanent <br /> cosmetic, branding, or body piercing procedures. <br /> Included with this cover letter is a Client Questionnaire and Consent Form template. The Kern County <br /> Environmental Health Division recommends that all body art facility owners use this template as a guide to <br /> develop forms that will be specific in obtaining records beneficial in protecting the health and safety of all <br /> potential clients. <br />