Silver Lily Tattoos LLC
213 N Water St. STE 1, Wilmington, IL 60481. (815)926-2309
Body Art Procedure Consent Form
Practitioner:
*
Nicole Klann
Lauren Juarez
Service:
*
Tattoo
Piercing
Client Information
Name
*
First Name
Last Name
Age
*
Birth Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pre-Procedure Questionnaire
Are you under the influence of drugs or alcohol?
*
Yes
No
Are you pregnant or nursing?
*
Yes
No
Do you have a communicable disease?
*
Yes
No
Do you have any skin conditions?
*
No
Yes
Skin conditions (e.g. Rashes, eczema, infection, psoriasis, freckles, etc.)
If yes, please identify the condition.
To ensure that your body art procedure heals properly, we ask that you disclose if you have or have had any of the following conditions. Disclosure will not prevent you from having a body art procedure.
Diabetes
Skin diseases or lesions
Sensitivities to soaps or cleaning products
Allergies to dyes, pigments, or latex
Epilepsy, seizures, fainting, or narcolepsy
Medications that effect blood clotting
Human immunodeficiency virus (HIV)
Hepatitis
Other
Acknowledgment and Waiver
*
I understand that this procedure is a permanent change to my skin and body.
*
I allow my tattoo or piercing to be photographed and be used for promotional and portfolio purposes.
*
I acknowledge that Silver Lily Tattoos does not offer refunds for tattoo or piercing services.
*
I agree that the Body Art Practitioner does not have a way of identifying if I am allergic to the elements or ingredients that will be used for my tattoo or piercing, and therefor will not hold the Body Art Practitioner or Silver Lily Tattoos responsible in the event of an allergic reaction.
*
I understand that I need to take care of the tattoo or piercing by following oral and written instructions given to me by the Body Art Practitioner.
*
I understand that I might get an infection if I don't follow the instructions given to me in regards of taking care of my tattoo or piercing.
*
I indemnify and hold harmless the studio, Silver Lily Tattoos LLC, and the Body Art Practitioner against any claims, expenses, damages, and liabilities.
*
I confirm that the information I provided in this document is accurate and true.
Signed Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client Signature
*
Please attach a photo of a valid state or military I.D. or Driver’s License.
*
Submit
Submit
Should be Empty: