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CLIENT INFO Name: Address: Phone number - Date: Date of Birth: Email: Emergency contact: Phone: Type of identeication Provided: Drivers License Passport Birth Certificate Apply a checb to t-7e,type of body art being performed: Tattoo Permanent Branding Piercing cosmetics Procedure Ste: MEDICAL HISTORY Description of Procedure: Please crcle any conditions listed below that apply to you. TB Asthma Eczema/Psoriasis Gonorrhea HIV h Hepatitis Heart Conditions Syphilis Herpes Skin pregnant/Nursing MRSA/Staph Conditions Infections JDiabetes Blood Fainting/Dizziness J Latex Allergies Thinners Antibiotic Epilepsy Hemophilia Scarring/Keloiding Allergies How long has it bean since you last ate? Do you have any Edditional allergies such as to metals, soaps, cosmetics or alcohol? Do you use ar y m _dications that might affect the healing of the body art you wish to receive? I 'IDo you have F history of herpes at the procedure site? Do you have 2 ny other medical or skin conditions that affect the outcome of yourprocedu-e? -have you eve- been prescribed antibiotics prior to dental or surgical procedures? o you have z ny cardiac valve disease? Is there any irforruation you feel you should provide to the body art practitioner? Other medica conditions? SWP-152 INFORMED CONSENT TO RECEIVE BODY ART PLEASE READ AND CHECK THE BOXES WHEN YOU ARE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OFSIGNING In consideration of receiving BODY ART from, the practitioner at (Name of the Practitioner) (together with its employees, (Name of Body Art Business( apprentices, and agents, the "Body Art Business") I confirm the following by initialing each applicable item: (Ulent's Name) NOTICE': 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 underthe age of 18 years old and have the presence of my parent or guardian to receive the body piercing. (Applicable only to underage body piercing. N/A if not applicable). 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 gf}estionnaire 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 orshown 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 ofthe restrictions. I understand that any medical information obtained will be subject to the federal Health Insurance Portability 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 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 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 the 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. I agree to immediately notify the artist in the event I feel lightheaded, dizzy and/or faint before, during or after the procedure. 11 (print name) 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 been informed of the potential risks associated with a body art procedure, I still wish to proceed with the body art application and I assume any and all risks that may arise from body art Signature of Client: Date: Signature of Practitioner: Date: 8/15/17