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CLIENT INFORMATION BODY ART CLIENT INFORMED CONSENT FORM Name: Age: Date of Birth: Phone: Address: Email: Emergency contact: Phone: PROCEDURE INFORMATION INFORMED CONSENT (Circle the body art being performed) Read and initial the boxes below to confirm the Tattoo Permanent Cosmetics information is understood Other: I am the person on the legal ID presented as ❑ proof that I am at least 18 years of age. Procedure Site: Type of ID: I am under the age of 18 years old and have the Description of Procedure: El the 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 ElMEDICAL HISTORY and that I am voluntarily submitting myself to receive body art without duress or coercion. Circle any conditions listed below that a D1v to vou I understand the permanent nature of receiving TB Asthma Antibiotic Allergies Hemophilia ❑ body art and that removal can be expensive HIV Hepatitis Cardiac Valve Scarring/ and may leave scars on the procedure site. Disease Keloiding The body art described or shown on the ❑Epilepsy Skin Pregnant/ MRSA/Staph consent form is correctly placed to my Conditions Nursing Infections specifications. Diabetes Blood Fainting/ Latex Allergies All questions about the body art procedure have Thinners Dizziness ❑ been answered to my satisfaction, and I have been given written aftercare instructions for the When was the last time you ate: procedure I am about to receive. I understand the restrictions on physical Do you have any additional allergies to metals, soaps, ❑ activities such as bathing, recreational water cosmetics, alcohol? activities, gardening, contact with animals, and the durations of the restrictions. Do you use any medication that might affect the healing I understand there is a possibility of getting an of the body art? infection and I am aware of the signs and symptoms, including, but not limited to redness, Do you have a history of herpes or any other skin ❑ swelling, tenderness of the procedure site, red conditions? streaks going from the procedure site towards Other medical conditions? the heart, elevated body temperature, or purulent drains a from the procedure site. Any allergies to shellfish? I understand that there is a chance I might feel lightheaded, dizzy during or after being Do you require antibiotics prior to surgery or dental ❑ tattooed. I will notify the artist immediately if procedures? this occurs. NOTICE: TATTOO INKs: Tattoo inks, dyes, and pigments that have not been approved by the Federal Food and Drug Administration have health consequences that are unknown. I acknowledge that the information that I have provided is true to the best of my knowledge. I have been fully informed of the potential risk 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.Aftercare has been explained and instructions have been provided. ❑ Aftercare Instructions were reviewed and provided Printed Client Name: Signature of Client: Date: Name of Practitioner: Body Art Facility Name: I have reviewed the client's information that was presented and have provided information on aftercare. All information provided by the client is correct, to the best of my knowledge. Practitioner Signature: Date: CPD BAP-013 Page 1 of 3 01/24