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0 RECEIVED <br /> P I" APR 0 7 2016 <br /> ENVIRONMENTAL HEALTjj <br /> INFORMED CONSENT TO BODY ART WORK PERMIT/SERVICES <br /> In consideration of receiving BODY ART from the Practitioner, <br /> at Port City Ink, I confirm the <br /> following by initialing each applicable item: <br /> _All questions about the Body Art work have been answered to my satisfaction, and I have <br /> been given written and verbal aftercare instructions for the Body Art work I am about to receive. <br /> _The Body Art has been described or shown to me and is correctly placed or drawn to my <br /> specifications. Describe tattoo and placement: <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 voluntarily submitting to <br /> Body Art work without duress or coercion. <br /> _I understand there is a possibility of an allergic reaction and getting an infection. <br /> _ I agree to follow all instructions concerning the care of my Body Art work, and that any <br /> touch-ups or repairs that may become needed due to my own negligence will be done at my <br /> own expense. <br /> _I understand that there is a chance I might feel lightheaded or dizzy during or after Body Art <br /> work. <br /> _ I agree to immediately notify the artist 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 <br /> Body Art including,but not limited to infection,scarring,difficulties in detecting melanoma,and <br /> allergic reactions to pigments, latex gloves, and antibiotics. Inks are not FDA approved and <br /> health consequences are unknown. Having been informed of the potential risks associated with <br /> obtaining Body Art, 1 still wish to proceed with the Body Art work and I assume any and all risks <br /> that may arise from the Body Art work. <br /> Signed Date <br /> i <br />