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Instrument Lot number Purchase date <br /> Instrument Lot number Purchase date <br /> Instrument Lot number Purchase date <br /> PLEASE READ AND CHECK THE BOXES WHEN YOU ARE CERTAIN YOU UNDERSTAND <br /> THE IMPLICATIONS OF SIGNING <br /> I confirm the following: <br /> 0 1 am the person on the legal ID presented as proof that I am at least 18 years of age. <br /> L1 I am not under the influence of alcohol or drugs. <br /> 11 1 understand that tattooing is permanent and that if I choose to have it removed,it may be expensive and <br /> leave scars. <br /> 11 1 understand there is a possibility of an allergic reaction to the inks and pigments commonly used in <br /> tattooing. <br /> 11 All questions about the body art procedure have been answered to my satisfaction,and I have been given <br /> written aftercare instructions for the tattoo I am about to receive. <br /> 11 1 understand that tattoo inks,dyes,and pigments have not been approved by the federal Food and Drug <br /> Administration and that the health consequences of using these products are unknown. <br /> El I understand there is a possibility of getting an infection,and I have been advised of the signs and <br /> symptoms of infection that indicate a need to seek medical attention. <br /> El I agree to follow all instructions concerning the care of my tattoo,and that any touch-ups needed due to <br /> my own negligence will be done at my own expense. <br /> L1 I understand that there is a chance I might feel lightheaded,dizzy during or after in tattooed. <br /> 0 1 agree to immediately notify the practitioner in the event I feel lightheaded,dizzy and/or faint before, <br /> 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 from <br /> tattooing. <br /> Signed <br /> Date <br />