BODY ART CONSENT FORM

PLEASE READ AND CHECK THE BOXES WHEN YOU ARE CERTAIN YOU

UNDERSTAND THE IMPLICATIONS OF SIGNING

In consideration of receiving BODY ART from

the practitioner at (Name of Body Art Business) apprentices, and agents, the "Body Art Business")

(Name of the Practitioner) (together with its employees,

confirm the following by initialing each applicable item:

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

Apply a check to the type of body art being performed:

I am the person on the legal ID presented as proof that I am at least

Please circle any conditions listed below that apply to you.

18 years of age. I am under the 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 Iam 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 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. 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 of the restrictions. I understand that any medical information obtained will be subject to the federal Health Insurance Portability and Accountability Act of 1996

*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. Iunderstand 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

How long has it been since you last ate?

Do you have any additional allergies such as to metals, soaps, cosmetics or

Do you use any medications that might affect the healing of the body art you wish to receive?

I will seek professional medical attention if signs and symptoms of

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

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 your procedure?

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.

Have you ever been prescribed antibiotics prior to dental or surgical procedures?

Do you have any cardiac valve disease?

Is there any information you feel you should provide to the body art practitioner?

(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, / still wish to proceed with the body art application and / assume any and all risks that may arise from body

If single-use, pre-packaged, pre-sterilized instruments and needles are used please maintain the following records: (1) A record of purchase and use of all single-use instruments. (2) A log of all procedures, including the names of the practitioner and client and the date of the procedure. (3) Written proof on company or laboratory letterhead showing that the presterilized instruments have undergone a sterilization process. Written proof shall clearly identify the instruments sterilized by name or item number and shall identify the lot or batch number of the sterilizer run.

The following verbal and/or written instructions were communicated to the client:

1. Information on the care of the procedure site. 2. Restrictions on physical activities such as bathing, recreational water activities, gardening, or contact with animals, and the duration of the restrictions. 3. 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. 4. Instructions to call a physician if any of the addressed signs and symptoms appear or for any other reason related to the Body Art procedure(s

If 5.physician care is required by the client related to the Body Art procedure(s), the client is to notify the Body Art facility and practitioner of the problem and the

resolution by a physician or clinic. This information shall be placed in the client's file.

To the best of my knowledge this information is correct:

I have received aftercare instructions: