Tattoo Consent Form

Desert Ink and Beauty Tattoo Consent Form
Name of Client
Address of Client
Date and time of appointment
Phone number

Area CodePhone Number
Date of Birth

MonthDayYear
Date
State License ID #: (Show proof of State ID)*
Photo of State License ID
Site of Procedure (body part)
For Clients Information

Known (potential) risks associated with tattooing
- Scarring
- Blood Poisoning (Septicaemia)
- Allergic Reaction to Pigment
- Localised Swelling Around The Site
Individual Consent

I declare that I give my full consent to the tattooing being carried out by the aforementioned practitioner. I confirm that potential complications, e.g. infection and swelling, for the procedure undertaken, and aftercare instructions have been explained to me. A written aftercare advice sheet containing more detailed information has been given to me and I agree that it is my responsibility to read this and follow the instructions on it, until the site has healed.

I confirm that all the information provided by me for this consent form is correct to the best of my knowledge, that I am over the age of consent for this procedure (i.e. 18 years old for tattoo), I have eaten in the last 4 hours, and that I am not currently under the influence of alcohol or drugs.

If you are a minor please continue filling out, the guardian potrion is near the bottom.
Signature of Client*
Date

MonthDayYear
Date
DiabetesHistory of hemophiliaHistory skin diseases, skin sensitivities to soap, disinfectants, etc.History of allergies or adverse reactions to pigments, dyes or otherDo you have any communicable diseases (i.e. hepatitis A, hepatitis B, HIV, or any other disease that may be transferred during the procedure)?Use of blood thinning medications in the last 24 hours? (anticoagulants, antiplatelet drugs, or NSAIDS (e.g. aspirin, ibuprofen,)Pregnant or nursingingested any medication that may inhibit the ability to heal a skin wound?Allergic to latex, iodinehistory of skin lesions or other skin sensitivity that might inhibit the healing of the body art procedure?Do you have high blood pressure, heart condition, heart disease, or any other conditions that may interfere with the body art procedure?Do you have epilepsy; a history of seizure, fainting, or narcolepsy; or other conditions that may interfere with the body art procedure?none
By singing below, I specifically acknowledge that I have been advised of the facts and matters set below and I agree as follows:
I acknowledge that there is a chance I might feel lightheaded, dizzy during or after being tattooed. I agree to immediately notify in the event I feel lightheaded, dizzy and/or faint before, during, or after the procedure. I understand and fully accept the risks with this procedure and hold Desert Ink and Beauty harmless from same.

I have informed the practitioner of any and all of my known allergies. I acknowledge that it is not always reasonably possible to advance whether I might have an allergic reaction to any of the pigments, dyes, topical preparations, or processes used in the and I agree to accept the risk that such reaction is possible.

I acknowledge that tattoo inks, dyes, and pigments have not been approved by the federal Food and Drug Administration and consequences of using these products are unknown.

I realize that my body is unique and neither Desert Ink and Beauty nor its employees or contractors can predict how my skin will react as a result of the procedure.

I acknowledge that the procedure may result in a permanent change to my appearance and that no representations made to me as to the ability to later change or remove the results.

I understand that future skin altering procedures such as laser treatments, plastic surgery, implants, and/or injections may alter and tattoo, and that I must inform any future service provider that I have had permanent tattoos applied. I understand and accept that are not the fault of Desert Ink and Beauty or its employees or contractors. I further understand that such changes or degradation may not be correctable through further tattoo procedures.

The nature and method of the proposed tattoo procedure has been explained to me as having the usual risks inherent in the procedure and the possibility of complications during and following its performance. I understand that there may be a certain amount of discomfort or pain associated with the procedure and that other possible adverse side effects may include: minor and temporary bleeding, bruising, redness, or other discoloration and/or swelling. Fading or loss of pigment may occur. Secondary infection in the area of the procedure is rare if properly cared for, but may occasionally occur.

I consent to the admittance of authorized observers to the procedure(s) for the purpose of education or assistance.
Client Signature*
YesNo
IF YES, I understand that correcting or touching up tattoos that was performed by others involves additional risks because of the existence of permanent pigments of unknown composition, brand, color, age, shape and other factors over which Desert Ink and Beauty has no control. I understand that additional appointments after the initial and follow-up appointments may be required, and will be billed at Desert Ink and Beauty standard rates. I understand that Desert Ink and Beauty cannot predict the results in advance and cannot guarantee and has not represented that the results will be as I desire. I understand and fully accept the risks associated with this procedure and hold Desert Ink and Beauty harmless from same.
I have looked over my design, checked the spelling if applicable, and give my full consent to the application of my tattoo.I consent to any relevant photographs being taken before, during, and after the procedure, to document the results of the and/or for educational purposes for use of Desert Ink and Beauty.I consent to Desert Ink and Beauty using "before & after" photos of me for marketing purposes to display.I have been given the full opportunity to ask any and all questions which I have, about obtaining Tattoo procedures from a specialist at Desert Ink and Beauty and that all of my questions have been answered to my full and total satisfaction.I agree to follow all instructions concerning the care of my tattoo, Desert Ink and Beauty will provide one free touch up, and that any touch ups needed after because of my own negligence will be done at my own expense.I acknowledge I have the opportunity to ask Desert Ink and Beauty questions before, during, and after the body art procedure.
YesNo
If YES, please specify.
By signing below, I acknowledge, understand and agree that: the staff at Desert Ink and Beauty do not practice medicine, does not accept health insurance, and have made no representation to the contrary; the information provided on this form is accurate and complete to the best of my knowledge, and that Desert Ink and Beauty, its staff, and students are not responsible for complications or problems arising from any incorrect or omitted information; some individuals will have complications related to tattoos. These complications are usually mild and last only a few days. However, extreme complications are always a possibility. I accept these risks and agree to hold Desert Ink and Beauty and its employees, contractors and students harmless for same; the staff at Desert Ink and Beauty will use the information provided above to assess my suitability for the proposed tattoo services.I am completely satisfied with my shape, color and overall work when I leave.
I have read and understand the contents of each statement above. I acknowledge that this is a contract and that I have received no warranties or guarantees with respect to the benefits to be realized from, or consequences of, the aforementioned procedure(s I further acknowledge that at the time of signing this consent I am of sound mind and capable of making independent decisions for myself.

If you have health or medical concerns, please consult a physician before engaging in a body art procedure. A client with a heart condition may have an increased risk of contracting bacterial endocarditis and should contact his or her physician before receiving any body art procedure
I HAVE READ AND UNDERSTAND ALL RISKS AND THE AFTERCARE INSTRUCTIONS. I ACCEPT THAT FAILURE TO FOLLOW THE POST-PROCEDURE INSTRUCTIONS IS NOT DESERT INK AND BEAUTY LIABILITY. NO GUARANTEES, NO REFUNDS.

BY SIGNING YOU ARE AGREEING TO EVERYTHING ABOVE.
Name (Please print)*
Client Signature*
Date*

MonthDayYear
Date
Practitioner statement: I have personally reviewed the above information with my client.
Practitioner Name (Please print)
Practitioner Signature
Date

MonthDayYear
Date
IF YOU ARE NOT A MINOR PRESS SUBMIT.

IF YOU ARE A MINOR HAVE YOUR GUARDIAN FILL THE NEXT PORTION OUT.
PARENT OR GUARDUIAN OF A MINOR
I am  (your name)   First Name   Last Name    the parent or legal guardian of (Please match clients name above)   First Name   Last Name   . What is the minors birthdate?  Date      . I am giving the minor my consent to get (what they are getting for the tattoo)      tattooed by Desert Ink and Beauty.
         Is this the minors first tattoo?
I give Desert Ink and Beauty my permission to tattoo (the minor above). I have read through the consent form and understand risks and aftercare that comes with getting a tattoo. I understand a tattoo is permanent. I understand I can ask Desert Ink and Beauty any questions.
   Signature         Date
DO NOT FILL OUT ANYTHING PAST THIS POINT. FOR DESERT INK AND BEAUTY

Owner of Desert Ink and Beauty and Tattooer: Emily Smith
Practitioner Print Name

First NameLast Name
Practitioner statement: I have personally reviewed the above information with my client.
Practitioner Signature
Date

MonthDayYear
Date
Type:
Lot # and Expiration date:
Should be Empty:

Desert Ink and Beauty Tattoo Consent Form

IF YOU ARE NOT A MINOR PRESS SUBMIT.

IF YOU ARE A MINOR HAVE YOUR GUARDIAN FILL THE NEXT PORTION OUT.

PARENT OR GUARDUIAN OF A MINOR

Owner of Desert Ink and Beauty and Tattooer: Emily Smith