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CLIENT INFO
<br />BODY ART CONSENT FORM
<br />Date:
<br />phonenumber. Data af8lrth:
<br />Erall: fT[IP
<br />Fmergenel [aRaR: Phone:
<br />7yPe o/Afen[7lmtton Provided:
<br />Ortvers License Pmport Birth Certificate
<br />ApPlYocherk to thetype ofbody ortbeingper/olmed'
<br />Tattoo Permanent ganding Plerdng
<br />cosmetics
<br />Procedure site: I Description a/proeedure:
<br />MEDICAL HISTORY
<br />circle
<br />pierce
<br />an mnamons nstea aerowrmre err r ry
<br />TB Asthma Eaema/Psorasls Gonorrhea
<br />HW Hepadw Heart Conditions Syphilis
<br />Herpes Skin Pregnant/Hursing MRSA/Saph
<br />Candidate
<br />IrdeWons
<br />Diabetes ?Bloom Falnting/Dbulnew face. Allergis
<br />e
<br />Amlblotk
<br />Epilepsy HemaphRla Sarring/Ilelolding pit les
<br />How long has k been since you last ate?
<br />W you have any additional
<br />ailergles such as to metals, soaps, cosmetla Dir
<br />akaho7
<br />Do you sae any mediations that might effect the holing of the body art you
<br />wish to receive?
<br />Da you have a history
<br />of herpes at the Dmredure sltei
<br />Do you have any other medical or skin conditions that affect the outcome Of
<br />yuurpromdum?
<br />Have you enirbeen presented andblotla priarto dental or surgical
<br />procedures?
<br />Do youlint anycxdlecwlved47
<br />H these any Information you feel you should provide to the body art
<br />pricdtioner?
<br />other medical
<br />conditlOns7
<br />k.�iof;$ 'fir
<br />INFORMED CONSENT TO RECEIVE BODY ART
<br />PLFASEREADAND CHECK THE BOXES WHEN IPU ARE CERTAIN YOU
<br />UNDEgSTAND 7 H IMPIIrATWNS OF SIGNING
<br />In mmideradon of receiving BOW ABThom, Ixorn., I
<br />the practitioner at (together wkh its employees,
<br />rr..raw.n•+�t
<br />apprentice% and agents, the 'Body Art Budness•)
<br />conflrm the following by Initialing each applicable item:
<br />lu+nvr!
<br />I li714toomla, dyes, oMNa^tena Uarhove noebeai approsedbY
<br />tM/ederol Food and Ong Adathdomdonhave heaWr coMegtlmaB that One
<br />wknown.
<br />_I am the person an the legal ID presented as proof that I am at least
<br />1g years orage.
<br />_ I am under the age of a years aid and have the presence of my
<br />pa rant or guardian to receive the body plerdng. (Appkabie Only
<br />un derage body pterurg, N/A H rat appacaNe).
<br />_ I am not under the Influence of alcohol or drugs and that I am
<br />voluntadNsubmitting myself to moewe body art without duress or coercion.
<br />_ I admawkdge that the Information that I have provided In the
<br />medial questionnaire is complete and We tothe best of my knowledge.
<br />I understand the permanent nature of receiving body an and that
<br />re novel an be expensive and may low start on the proceduashe.
<br />_The body an described orshown on the client record form Is
<br />mrmatty placed to myspecifications-
<br />_ All
<br />petlflations._All questions about the body art procedure have been arisWered W
<br />my saUsbalon, and I have been given written aftercare Instructions far the
<br />procedure I am about to receive.
<br />_ I understand the restrfcdQm on physical aNaides' ueh os bathing,
<br />recreational water a Wvides, gardering, contact with animals, and the
<br />duratlons of the restrictions.
<br />_ I understand that any medical Information obtained will be subject to
<br />Ihefederal "with Imuranm Portability and Accountability Act of 1996
<br />(HIPPA),
<br />9 am awarethat tattoo inks4 dyes, and pigments used on the
<br />p owdum she haw not been approued by the federal Food and Drug
<br />Administration, and that the health consequences of wing these products
<br />are unlatown.
<br />I am aware of the slims and symptoms of Infection, Including, but not
<br />limit_ed to redness, swelling, tenderness of the procedure shet red streaks
<br />going from the procedure she towards the heart, elevated body
<br />temperature, or purulent drainage from the procedure she.
<br />_ I undersand there is a possibility of getting an Infection aaa result of
<br />receMng body art particularly In the event that I d0 not take proper are of
<br />the proeedureslte.
<br />_ I will seek professlonal medical attention If signs and symptoms of
<br />Irdaction occur.
<br />I agree to fallow all Institutions concerning the ase of myattoo,
<br />and that any toudrups needed due to my own negligence will be done at my
<br />own eapense.
<br />I undersand that there Is a diance I might feel lightheaded, ditty
<br />auOng or enter bang tattooed.
<br />I agree to Immedistaty notdy the Grist In the event 1 feet
<br />lightheaded, dlaty and/or faint before, during or afar the procedure.
<br />4
<br />(Print WW) have been/u/y
<br />tnjomNa/dw&AF lboMart Including but not tlmhedto mhctwn
<br />storrhq, dlJjlcvldesIn detecting mekvnoM mrd alkrykreallons to tatow
<br />pfpmea4 law jibves, and aMtbmtkx Hm"been Informed! of the fotential
<br />risks associated with a body art procedure, Isdgwish toproteed with the
<br />6odyartopplkWon and I assume any and Off risks that May unbcI am 6ady
<br />ort.
<br />S�reture of CIIenG
<br />Sigrtature oFPnNdoeeeu ��
<br />8/i5J17
<br />How long has k been since you last ate?
<br />W you have any additional
<br />ailergles such as to metals, soaps, cosmetla Dir
<br />akaho7
<br />Do you sae any mediations that might effect the holing of the body art you
<br />wish to receive?
<br />Da you have a history
<br />of herpes at the Dmredure sltei
<br />Do you have any other medical or skin conditions that affect the outcome Of
<br />yuurpromdum?
<br />Have you enirbeen presented andblotla priarto dental or surgical
<br />procedures?
<br />Do youlint anycxdlecwlved47
<br />H these any Information you feel you should provide to the body art
<br />pricdtioner?
<br />other medical
<br />conditlOns7
<br />k.�iof;$ 'fir
<br />INFORMED CONSENT TO RECEIVE BODY ART
<br />PLFASEREADAND CHECK THE BOXES WHEN IPU ARE CERTAIN YOU
<br />UNDEgSTAND 7 H IMPIIrATWNS OF SIGNING
<br />In mmideradon of receiving BOW ABThom, Ixorn., I
<br />the practitioner at (together wkh its employees,
<br />rr..raw.n•+�t
<br />apprentice% and agents, the 'Body Art Budness•)
<br />conflrm the following by Initialing each applicable item:
<br />lu+nvr!
<br />I li714toomla, dyes, oMNa^tena Uarhove noebeai approsedbY
<br />tM/ederol Food and Ong Adathdomdonhave heaWr coMegtlmaB that One
<br />wknown.
<br />_I am the person an the legal ID presented as proof that I am at least
<br />1g years orage.
<br />_ I am under the age of a years aid and have the presence of my
<br />pa rant or guardian to receive the body plerdng. (Appkabie Only
<br />un derage body pterurg, N/A H rat appacaNe).
<br />_ I am not under the Influence of alcohol or drugs and that I am
<br />voluntadNsubmitting myself to moewe body art without duress or coercion.
<br />_ I admawkdge that the Information that I have provided In the
<br />medial questionnaire is complete and We tothe best of my knowledge.
<br />I understand the permanent nature of receiving body an and that
<br />re novel an be expensive and may low start on the proceduashe.
<br />_The body an described orshown on the client record form Is
<br />mrmatty placed to myspecifications-
<br />_ All
<br />petlflations._All questions about the body art procedure have been arisWered W
<br />my saUsbalon, and I have been given written aftercare Instructions far the
<br />procedure I am about to receive.
<br />_ I understand the restrfcdQm on physical aNaides' ueh os bathing,
<br />recreational water a Wvides, gardering, contact with animals, and the
<br />duratlons of the restrictions.
<br />_ I understand that any medical Information obtained will be subject to
<br />Ihefederal "with Imuranm Portability and Accountability Act of 1996
<br />(HIPPA),
<br />9 am awarethat tattoo inks4 dyes, and pigments used on the
<br />p owdum she haw not been approued by the federal Food and Drug
<br />Administration, and that the health consequences of wing these products
<br />are unlatown.
<br />I am aware of the slims and symptoms of Infection, Including, but not
<br />limit_ed to redness, swelling, tenderness of the procedure shet red streaks
<br />going from the procedure she towards the heart, elevated body
<br />temperature, or purulent drainage from the procedure she.
<br />_ I undersand there is a possibility of getting an Infection aaa result of
<br />receMng body art particularly In the event that I d0 not take proper are of
<br />the proeedureslte.
<br />_ I will seek professlonal medical attention If signs and symptoms of
<br />Irdaction occur.
<br />I agree to fallow all Institutions concerning the ase of myattoo,
<br />and that any toudrups needed due to my own negligence will be done at my
<br />own eapense.
<br />I undersand that there Is a diance I might feel lightheaded, ditty
<br />auOng or enter bang tattooed.
<br />I agree to Immedistaty notdy the Grist In the event 1 feet
<br />lightheaded, dlaty and/or faint before, during or afar the procedure.
<br />4
<br />(Print WW) have been/u/y
<br />tnjomNa/dw&AF lboMart Including but not tlmhedto mhctwn
<br />storrhq, dlJjlcvldesIn detecting mekvnoM mrd alkrykreallons to tatow
<br />pfpmea4 law jibves, and aMtbmtkx Hm"been Informed! of the fotential
<br />risks associated with a body art procedure, Isdgwish toproteed with the
<br />6odyartopplkWon and I assume any and Off risks that May unbcI am 6ady
<br />ort.
<br />S�reture of CIIenG
<br />Sigrtature oFPnNdoeeeu ��
<br />8/i5J17
<br />
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