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INFORMED CONSENT TO BODY ART PLEASE READ AND CHECK THE BOXES WHEN YOU ARE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SIGNING In consideration of receiving BODY ART from the practitioner at (Nanat of the Pradidauff) (together with its employees,apprentices,and agents,the"Body Art BoAness") i Now of Ta nno RaWssess) I confirm the following by initialing each applicable item: Wheat's N *QjWjjjS: Tattoo)inks,dyes,and pigments that have not been approved by the federal Food and Drug Administration have health consequences that are unknown. — I am the person on the legal ID presented as proof that I am at least 18 years-of age- - I am under the age of 18 years old and have the presence of my parent or guardian to receive the body piercing andern InIII11 Ugallmbk g&to Im ILL.1111:1111 2L3WdkWWd- 11111.11 i 1,11III I N6,i 4 — I am not under the influence of alcohol or drugs and that I am voluntarily submitting myself to receive body art without duress or coercion. — I acknowledge that the information that I have provided in the nodical questionnaire is complete and true to the best of my knowledge. — I understand the permanent nature of receiving body art and that re gal 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. — All questions about the body art procedure have been answered to my satisfaction,and I have been given written aftercare instructions for the procedure I am about to receive, — I understand the restrictions on physical activities such as bathing, recreational water activities,gardening,contact with animals, and the durations of the restrictions. — I understand that any medical information obtained will be sub*-t to the federal Health Insurance Ponubility and Accountability Act of 1996(HIPPA). — I am aware that tattoo inks,dyes,and pigments used on the procedure site have not been approved by the federal Food and Drug Administration. and that the health consequences ofusing these product%are unknown, — I and aware of the signs and symptoms of infection,including,but not limited to redness,swelling,tenderness of the procedure site, red streaks going frorn 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 receiving body art particularly in the event that I do not take proper care of the procedure site.