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Port City 1 In consideration of receiving BODY ART from , the practitioner at Port City Ink(together with its employees, apprentices, and agents, the"Body Art Business") I confirm following by initialing each applicable item: I am the person on the legal ID presented as proof that I am at least 18 years of age. 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 medical questionnaire is complete and true to the best of my knowledge. I understand the permanent nature of receiving body art and that removal 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 subject to the federal Health Insurance Portability and Accountability Act of 1 ( IPPA). 1 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 of using these products are unknown. I am aware of the signs and symptoms of infection, including, but not limited to redness, swelling, tenderness of the procedure site, red streaks going from the procedure site towards the heart, elevated body temperature, or purulent drainage from the procedure site. I understand there is a possibility of an allergic reaction and 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. I will seek professional medical attention if signs and symptoms of infection occur. I agree to follow all instructions concerning a care of my tattoo, and that any touch- ups needed due to my own negligence will be done at my own expense. I understand that there is a chance I might feel lightheaded, dizzy during or after being tattooed. 1 agree to immediately notify the artist in the event 1 feel lightheaded, dizzy and/or faint before, during or after the procedure. 1, have been fully informed of the risks of body art including but not limited to infection, scarring, difficulties in detecting melanoma, and allergic reactions to tattoo pigment, latex gloves, and antibiotics. Having informed of the potential risks associated with a body art procedure, and that the inks are not FDA approved and health consequences are unknown; I still wish to proceed the body art application and I assume any and all risks that may arise from body art. Signature fClient: ate: Signature of Practitioner: :