Dreamline Tattoo and Piercing State Consent Form

  • STATE OF MISSOURI DIVISION OF PROFESSIONAL REGISTRATION

  • First and foremost, we want to thank you for wanting to participate in our fundraiser. However, this does not guarantee you a slot for the fundraiser. This event is a first come, first served event. This is to speed up the paperwork and get you on the list quicker.

  • PATRON CONSENT

  • OFFICE OF TATTOOING, BODY PIERCING AND BRANDING

    3605 MISSOURI BOULEVARD

    PO BOX 1335

    JEFFERSON CITY, MO 65102-1335

    TELEPHONE: (573) 526-8288

    FAX: (573) 526-3489

     

  • PATRONS DATE OF BIRTH
     / /

  • PATRON'S DRIVER LICENSE NUMBER (must have driver's lisence the day of the event for confirmation purposes)

    YOU MUST BE THE AGE OF EIGHTEEN, PLEASE SUBMIT DRIVER LICENSE NUMBER.

  • What will you be getting at the event? (Pick all that apply)
  • Are you currently or have you ever used medications that contain a controlled substance?
  • Have you ever been diagnosed by a medical doctor as to having contracted communicable disease such as Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and/or other blood borne pathogens? If so,when?
  • Have you ever been diagnosed by a medical doctor as having allergies?
  • Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?
  • Are you currently under the influence of any illegal substances?
  • Are you currently under the influence of an alcoholic beverage?
  • Have you been diagnosed with jaundice within the past twelve months?
  • Are you currently using any medications that contain blood thinners?
  • Are you currently using any medications that weaken the immune system that fightsinfections?
  • Should be Empty: