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tnrwmrnicrobladin rirhes.com BODY ART CONSENT FORM CLIENT INFO INFORMED CONSENT TO RECEIVE BODY ART PLEASE READ AND CHECK THE BOXES WHEN YOU ARE CERTAIN YOU Name: Date: UNDERSTAND THE IMPLICATIONS OFSIGNING Address: In consideration of receiving BODY ART from, (Name of the Practitioner) Phone number: Date of Birth: the practitioner at (together with its employees, (Name of Body Art Business) Email: I-t�iP, apprentices,and agents,the"Body Art Business") I confirm the following by initialing each applicable item: Emergency contact: Phone: (atenr:Name) Type of Identification Provided: NOTICE*.Tattoo inks,dyes,and pigments that have not been approved by the federal Food and Drug Administration have health consequences that are Drivers License Passport Birth Certificate unknown. I am the person on the legal ID presented as proof that 1 am at least Apply a check to the type of body art being performed: 18 years of age. Permanent I am under the age of 18 years old and have the presence of my Tattoo Branding Piercing cosmetics 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 1 am Procedure Site: Description of Procedure: 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. MEDICAL HISTORY All questions about the body art procedure have been answered to my satisfaction,and I have been given written aftercare instructions for the Please circle any conditions listed below that apply to you. procedure I am about to receive. I understand the restrictions on physical activities'such as bathing, TB Asthma Eczema/Psoriasis Gonorrhea recreational water activities,gardening,contact with animals,and the durations ofthe restrictions. HIV Hepatitis Heart Conditions Syphilis I understand that any medical information obtained will be subject to Skin MRSA/Staph the federal Health Insurance Portability and Accountability Act of 1996 Herpes Conditions Pregnant/Nursing Infections (HIPPA). Blood 'I am aware that tattoo inks,dyes,and pigments used on the Diabetes Fainting/Dizziness Latex Allergies procedure site have not been approved by the federal Food and Drug Thinners Antibiotic Administration,and that the health consequences of using these products Epilepsy H r�ophilia Scarring/Keloiding are unknown. oY C VS Allergies id[ Ih9 ISCY r7 I am aware of the signs and symptoms of infection,including;but not limited to redness,swelling,tenderness of the procedure site,red streaks How long has it been since you last ate? 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 Do you have any additional allergies such as to metals,soaps,cosmetics or receiving body art particularly in the event that I do not take proper care of alcohol? the procedure site. I will seek professional medical attention if signs and symptoms of Do you use any medications that might affect the healing of the body an you infection occur. wish to receive? 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 Do you have a history of herpes at the procedure site? own expense. I understand that there is a chance I might feel lightheaded,dizzy Do you have any other medical or skin conditions that affect the outcome of during or after being tattooed. your procedure? I agree to immediately notify the artist in the event I feel lightheaded,dizzy and/or faint before,during or after the procedure. Have you ever been prescribed antibiotics prior to dental or surgical procedures? 11 (printname)have been fully informed of the risks of body art including but not limited to infection, Do you have any cardiac valve disease? 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,1 still wish to proceed with the is there any information you feel you should provide to the body an body art application and I assume any and all risks that may arise from body practitioner? art. Other medical conditions? Signature of Client: Date: CA 6e—(' r 1j� �YS for ico rh (� Signature of Practitioner: Date: SWP-152 t 8/15/17