Tattoo and Permanent Cosmetic Consent Form

Tattoo and Permanent Cosmetic Consent Form
Name

First NameLast Name
Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Short description of procedure, design and placement
Date of Birth

MonthDayYear
Date
Please upload a clear photo of the front of your ID. (Has to be present and showed to the practitioner, as well as uploaded, to be valid)

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Do you have diabetes?
Are you currently undergoing chemotherapy?
Do you have HIV/AIDS
Do you take cholesterol or blood pressure medication?
Have you had any Botox or other injectables in the last 2 weeks?
Do you take any blood thinning medication?
Do you take any thyroid medication?
Are you pregnant or nursing?
Are you allergic to latex or any kind of adhesive?
Other risk factors for bloodebourne pathogen exposure?
This includes: HIV/AIDS, Hepatitis B and Hepatitis C
Do you have any skin conditions in the procedure area?
This includes: Scars, keloids, eczema, or an active breakout.
If yes, please explain.
Do you have cardiac valve disease?
Are you prone to fainting or dizziness?
Do you have epilepsy?
Have you ever had or currently have T.B.?
Do you have asthma?
Do you have a history of herpes infections in the procedure site?
Do you have a history of hemophilia or other bleeding disorders?
Are you allergic to antibiotics?
Do you use any medication that might effect the healing process of your procedure?
Please list any current medications your taking.
Have you ever been prescribed antibiotics prior to surgery or dental procedures?
How long has it been since you last ate?

This tattoo is created by injecting ink into into your skin. To do this I will use an electrically powered tattoo machine or handheld blade. The machine moves a solid needle up and down to puncture the skin between 50 and 3000 times per minute. The needle penetrates the skin by about a millimeter and deposits a drop of insoluble ink into the skin with each puncture. Any puncture wound has the potential for infection and disease transmission.
The healing process follows a four stage healing timeline that includes oozing, itching, peeling and continued aftercare. It's important to be consistent about aftercare so your tattoo doesn't get infected. If you see any signs that your tattoo isn't properly healing or signs of infection including: Fever, waves of heat and cold, abnormal shivering, swelling Of the tattooed area, pus, red lesions around the area, red streaking from the area, or areas of hard, raised tissue, see your doctor as soon as possible. Be advised that tattoo inks are not FDA approved and health consequences are unknown.
I have been informed of the nature, risk, and possible complications and consequences of permanent skin pigmentation. I understand the permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedure. Including but not limited to; infection, scarring, inconsistent color, spreading, thinning or fading of pigments. I understand that the actual color of the pigment maybe modified slightly, Due to tone and color of the skin. I fully understand this is a tattoo process and therefore not an exact science, but an art. I request the permanent skin pigmentation procedure('s) And except the permanence of the procedure as well as possible complications and consequences of said procedure('s).
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There is a possibility of allergic reaction to pigments and after care covering. The patch test is advisable however it does not insured a client will not have an allergic reaction. Please initial one of the following.

If waived, I release the practitioner from liability if I develop an allergic reaction to the pigment or after care covering.
Please initial ONE after reading the above statement.
I consent to a patch test. blanks
I waive the patch test blank
I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my tattoo/permanent cosmetics. I have acknowledged some of these potential adverse changes may not be correctable.
Signature

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I understand that the taking of before and after photos of said procedure or a condition of such procedures and maybe used online/social media for marketing purposes.

I certify that I have read and initialed the above paragraphs and I have been explained to my understanding this consent and procedure permit. I accept full responsibility for the decision to have this tattoo/permanent cosmetics work done.
Signature

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**PRACTITIONER USE ONLY** Please leave blank!

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