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47
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1
Legal Name
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First Name
Last Name
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2
Preferred Name
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First Name
Last Name
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3
Pronouns
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4
Birthdate
*
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-
Date
Year
Month
Day
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5
Legal Guardian Name
*
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First Name
Last Name
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6
Phone Number
*
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Please enter a valid phone number.
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7
Do you have any of the following medical conditions?
*
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Check ALL that apply
HIV
Hepatitis
TB
Herpes
Diabetes
Asthma
Epilepsy
Skin conditions
Blood Thinners
Hemophilia
Eczema/Psoriasis
Heart Conditions
Gonorrhea
Syphilis
Latex Allergies
MRSA/ Staph
Pregnant/Nursing
Fainting/Dizziness
Scarring/Keloiding
Antibiotic Allergies
NONE OF THESE
Other
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8
Do you have a history of herpes at the procedure site?
*
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YES
NO
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9
Do you have any cardiac valve disease?
*
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YES
NO
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10
Do you have any other risks for blood borne pathogens exposure?
*
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ie- working in the medical field etc.
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11
Do you have any additional allergies such as to metals, soaps, cosmetics or alcohol?
*
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12
Do you use any medications that might affect the healing of the body art you wish to receive?
*
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13
Do you have a history of medication use or are you currently using medication, including being prescribed antibiotics prior to dental or surgical procedures?
*
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14
Is there any information that you feel you should provide to the body art practitioner?
*
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15
In consideration of receiving BODY ART from the practitioner at VELVET ORANGE BODYCRAFT (together with its employees, it’s apprentices, and agents, the “Body Art Business”) I confirm the following by initialing each applicable item:
*
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I am under the age of 18 years old and have the presence of my parent or guardian to receive the body piercing.
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16
*
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I am not under the influence of alcohol or drugs and that I am voluntarily submitting myself to receive body art without duress or coercion.
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17
*
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I acknowledge that the information that I have provided in the medical questionnaire is complete and true to the best of my knowledge.
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18
*
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I understand the permanent nature of receiving body art and that removal can be expensive and may leave scars on the procedure site.
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19
*
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The body art described or shown on the client record form is correctly placed to my specifications.
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20
*
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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.
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21
*
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I understand there are restrictions on physical activities such as bathing, recreational water activities, gardening, and contact with animals for 6 weeks
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22
*
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I understand that any medical information obtained will be subject to the federal Health Insurance Portability and Accountability Act of 1996 (HIPPA).
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23
*
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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.
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24
*
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I understand 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 the procedure site.
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25
*
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I will seek professional medical attention if signs and symptoms of infection occur.
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26
*
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I agree to follow all instructions concerning the care of my tattoo or piercing, and that any touch-ups needed due to my own negligence will be done at my own expense.
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27
*
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I understand that there is a chance I might feel lightheaded, dizzy during or after being tattooed or pierced.
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28
*
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I agree to immediately notify the artist in the event I feel lightheaded, dizzy and/or faint before, during or after the procedure.
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29
*
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I understand that physical distancing will not be possible during this procedure and that by undergoing this procedure I may increase my risk of contracting pathogens including but not limited to COVID-19.
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30
*
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I understand that body piercing can result in nerve damage, bone and tooth loss, and that if I choose to remove my jewelry, permanent holes or scars may be left.
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31
*
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I understand that all piercings pose risks including but not limited to; infection, migration, stretching, tearing and/or rejection.
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32
*
This field is required.
I understand there is a possibility of an allergic reaction to the jewelry inserted into the fresh body piercing.
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33
I; the CLIENT 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, I still wish to proceed with the body art application and I assume any and all risks that may arise from body art.
*
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34
I; the Legal Guardian 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, I still wish to proceed with the body art application and I assume any and all risks that may arise from body art.
*
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Clear
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35
I have received Aftercare Instructions
*
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36
Today’s Date
-
Date
Year
Month
Day
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37
Practitioner
*
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Shar
Delia
Shar
Delia
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38
Identification
ID/DL
Birth Certificate
Passport
Tribal ID
Other
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39
Piercing Type
*
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Ear
Body
Mouth
Nose
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40
Piercing Description
*
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41
Jewelry Quantity
*
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42
Gauge
*
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18
16
14
20
Other
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43
Length
*
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44
Material
*
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Titanium
Gold
Niobium
Other
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45
Jewelry Description
*
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46
To the best of my knowledge this information is correct
*
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47
Needle Packets
*
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