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CONSENT TO TATTOO PROCEDURE NAME: -------------------- -----Date ---- D.O.B: City: _ '111 State/Zip: Phone: Address: I acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions which I might have about the obtaining of a tattoo and that all of my questions have been answered to my full satisfaction. I also acknowledge that NO INK is FDA approved, health consequences are unknown, TATTOOS ARE PERMANENT, and that variations in color and design may happen depending on my skin type and complexion. Description Of Tattoo: _ _ _ _ _ _ _ _ _ _ Placement 9f Tattoo- Please check as applicable: Yes No I am 18 years of age or older: I am pregnant and/or nursing: I have a history of Herpes at/or around the procedure site: I have a history of Diabetes: I have a history of Latex allergies: I have a history of allergies to Antibiotics: Please List: ____C______________________ 1 have a history of Hemophilia or other bleeding disorders: I have a history of Cardiac Valve Disease or other Heart diseases: I have a history of AIDS/HIV: I have a history of Hepatitis A,B, or C: Please list any current medications: _ I have prescribed medications needed prior to dental surgical procedures: Please List: _________________ Other risk factors for Blood borne pathogens: _ I am under the influence of drugs and/or alcohol: Further more, ifl have any condition that may interfere with the tattoo procedure or affect the healing of the tattoo such as but not limited to; acne, scarring (keloid) eczema, psoriasis, freckles, moles, sunburn, or ANY type of infection or rash on my body I will advise my Tattoo Artist. I will also advise my Tattooer of any allergies to any metals, latex, soaps, or medications and acknowledge it is not reasonably possible for the tattooer to determine whether I might have an allergic reaction to the procedure or pigments used, but such reactions are always a risk. I acknowledge that infection is always possible in the obtaining of a tattoo, particularly in the event that I do not take proper care of my tattoo. The tattooer has informed me to expect soreness/tenderness at the procedure site, along with mild swelling and/or light itching during the healing process. I agree to follow the aftercare instructions given to me, by my tattooer, during the healing process, and any touch ups due to my own negligence will be done at my own expense. By signing this document I am agreeing that everything is completed to the best of my knowledge and that I have read and understand all guidelines set forth above. Client Signature: Date: ------------------- Artist Signature: Date: