Wisconsin Department of Safety and Professional Services

Wisconsin Department of Safety and Professional Services
Madison, WI 53708-8935 | Fax#:(608)251-3036 | Phone#:(608) 266-2112

Office Location: 4822 Madison Yards Way Madison, WI 53705

E-Mail: dsps@wisconsin.gov | Website: http://dsps.wi.gov
DIVISION OF PROFESSIONAL CREDENTIAL PROCESSING
INFORMED CONSENT TO TATTOO PROCEDURE
Under Wis. Admin. Code § SPS 221.10(1a), a tattooist may not tattoo a patron without first obtaining the signed, informed consent of the person on a form approved by the Department of Safety and Professional Services (Department
PATRON INFORMATION:
NAME:(first, last, MI)*
ADDRESS: (street, city, state, zip)*
AGE (IE: 25)*
Birth Month (IE: 02)*
Enter in numbers on
Birth Day (IE: 21)*
The day you were born
Birth Year (IE: 1985)*
4 digit year
Are you under the influence of any alcohol or mind-altering drug? (if yes, provide details)*

YesNo
Are you under the influence of any alcohol or mind-altering drug? (if yes, provide details)
Do you have any skin lesions or skin infections near the bodily area to be tattooed? (if yes, provide details)*

YesNo
Do you have any skin lesions or skin infections near the bodily area to be tattooed? (if yes, provide details)
Date*

MonthDayYear
Date
PRINT YOUR NAME HERE*
Signature*
Affidavit of Tattooist Only:

This section is to be signed by the tattooist completing the tattoo procedure.
I declare that I am the tattooist referred to on this form and performing the tattooing procedure on the patron as indicated above. I further declare that I have reviewed the information provided by the patron on this form prior to performing any tattooing procedure. I understand that failure to comply with the statutes and/or administrative code provisions of the licensing authority will be cause for license discipline and/or further legal action. By signing below, I am signifying that I have read the above statements and understand the obligation I have as a tattooist.
Date*

MonthDayYear
Date
Tatooist Name*
Tattooist Signature*
- The Department of Safety and Professional Services has statutory authority to promulgate rules regulating tattooists and tattooing establishments, per Wis. Stat. § 463.10(4
- No person under 18 years of age may be tattooed, except by a physician in the course of the physician’s professional practice, as permitted under s. 948.70 (3), Stats.
- A tattooist may not tattoo a person who appears to be under the influence of alcohol or a mind−altering drug or a person who has evident skin lesions or skin infections in the area of the procedure.
- Every tattooist shall keep a record of each patron, which shall include the patron’s name, address, age and consent form, the name of the practitioner doing the procedure and any adverse effects arising from the procedure. A patron’s record shall be retained for a minimum of 2 years following completion of the procedure.
#3204 (Rev. 10/18) Ch. 463, Stats.
Committed to Equal Opportunity in Employment and Licensing
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Wisconsin Department of Safety and Professional Services

DIVISION OF PROFESSIONAL CREDENTIAL PROCESSING

INFORMED CONSENT TO TATTOO PROCEDURE

PATRON INFORMATION:

Affidavit of Tattooist Only:

Committed to Equal Opportunity in Employment and Licensing