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■ Record - TAooina & Piercinatformed Consent <br /> Last Name: First Name: MI: <br /> Date of Birth: I I ex: M / F Phone: <br /> Address: <br /> Emergency Contact Name & Number: Phone: <br /> DESCRIPTION OF PROCEDURE: <br /> Name of Artist performing procedure: <br /> (PIERCING ONLY) <br /> Name of Guardian giving consent if client is under the age of 18: _1D <br /> PLEASE READ & INITIAL THE BOXES WHEN YOU ARE CERTAIN YOU UNDERSTAND THE <br /> IMPLICATIONS OF SIGNING <br /> All questions about the body art procedure have been answered to my satisfaction, and I have <br /> been given aftercare instructions for the procedure i am about to receive. <br /> The Body Piercing described is correctly placed to my specifications. <br /> The Tattoo described is drawn & placed to my specifications. <br /> I understand that Tattooing is permanent and that if i choose to have it removed, it may be <br /> expensive 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 submitting to be Tattooed without <br /> duress or coercion. <br /> I understand that there is a possibility of a allergic reaction. <br /> I understand that there is a possibility of an infection. <br /> I agree to follow all instructions concerning the care of my procedure, and that any touch-ups <br /> needed due to my own negligence will be done at my own expense. <br /> I understand that there is a chance I may feel lightheaded or dizzy during or after being Tattooed or <br /> Pierced. <br /> I agree to immediately notify the artist in the event I feel lightheaded, dizzy and/or faint before, <br /> before, during or after the procedure. <br /> 1, have been fully informed of the risks of my procedure including but not limited to <br /> infection, scaring, difficulties in detecting melanoma, and allergic reactions to tattoo pigment, latex gloves, and <br /> antibiotics. Having been informed of the potential risk associated with my procedure , I still wish to proceed <br /> with my procedure and I assume any and all risk that may arise from receiving my procedure. <br /> Signed: Date: <br />