Deadwood Ink Tattoo Consultation Form

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Date

Emergency Contact

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Technician Name

Welcome to Deadwood Ink LLC, thank you for booking with me! I can't wait to make your tattoo goals a reality! Please be aware some services should not be performed under certain medical condition. It is your responsibility to inform the body art technician of any pre-existing conditions, limitations or specific sensitivities and to inform your body art technician if you feel any discomfort during the session. You understand and voluntarily accept any risk associated with any given body art service or use of any of the company’s facilities, and hereby release Deadwood Ink LLC and any of its employees from all liability for any injury, including & without limitation to: personal, bodily or mental injury, economic loss or any damage to you resulting there from any such injury or damage resulting from your failure to disclose any pre-existing condition, limitation or specific sensitivities, or your failure to inform your body art technician of any discomfort during the session. Your body art technician may determine that it is unsafe for you to proceed with or continue a session due to health related concerns. In this event you may be required to provide a physician's medical release prior to continuing treatment.

I hereby consent to and authorize the technician/esthetician to perform tattooing procedures on me

*Please note that at Lane Beauty Bar LLC we do NOT accept minors for any body art procedure and you will be required to show ID prior to your appointmet

Front of ID

Back of ID

Health Questionnaire Please Check All That Apply

Any recent surgery, If so what?

I acknowladge that I may require additional treatments/procedures to obtain the expected results at an additional cost.

I understand the importance of following all instructions given to me. In the event that I have additional questions or concerns regarding my treatment or post-treatment care, I will consult the technician/esthetician immediately. I understand that if I choose to consult a physician, I do so at my own expense.

Signature

AFTERCARE

Wash 2x daily with a mild scent free soap to remove bacteria
Gently pat dry with a clean tissue
Do not use any cleansing products containing: glycolic, lactic, or AHA acids, or any kind of exfoliants (chemical or mechanical scrubs)
Apply a small amount of after care cream (do not over saturate your tattoo) reply 3 times a day. If you have extremely dry skin or notice the cream is completely dried up feel free to apply more as needed.

IMPORTANT REMINDERS

Wash hands before touching the procedure area
Do not pick at or exfoliate scabs, let them fall off naturally
Avoid excessive sweating for 1.5 weeks
Avoid direct sunlight or tanning for 4 weeks
Avoid long hot showers or excessive exposure to water for the first 10 days
Keep your tattoo out of bodies of water such as: pools, tubs, lakes etc. These hold bacteria which we would like to keep away from your tattoo so it can heal properly.
The healing process can take 3-4 weeks remember everyone heals differently, give your body time to heal and DON'T PICK

SIGNS OF INFECTION INCLUDE BUT ARE NOT LIMITED TO

Fever
Rash
Blisters
Sores that may have crusting
Chills
Sweating
Vomiting
Weakness
Drowsiness
Worsening pain
Continued redness or discoloration

*If you notice one or more of these symptoms please contact a certified health care provider.

Requested in the Client Consultation/Health History form. I have cited all conditions and circumstances regarding my health history, allergies, and medications, supplements, or prescriptions being taken (orally and/or topically), and any past reactions to products or medications.

Advertising, and Promotional Purposes.

I understand that if I have any concerns, I will address these with my technician/esthetician. I give permission to my technician/esthetician to perform the above treatment/procedure we have discussed and will hold them harmless and nameless from any liability that may result from this treatment/procedure. I understand my technician/esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs and that I have been provided sufficient opportunity for discussion and to have any questions answered. I understand the procedure and accept the risks. I do not hold the technician/esthetician, who was stated previously, responsible for any of my conditions that were present but not disclosed at the time of this procedure that may be affected by the treatment performed today.

Disclosure Statement and Notice for Filing Complaints

Public Act 375, which was enacted in December of 2010, indicates that individuals shall not tattoo, brand, or perform body piercing on another individual unless the tattooing, branding, or body piercing occurs at a body art facility licensed by the Michigan Department of Health and Human Services. Body art facilities are required to be in compliance with the “Requirements for Body Art Facilities,” which provide guidelines for safe and sanitary body art administration. As with any invasive procedure, body art may involve possible health risks. These risks may include, but are not limited to: transmissions of bloodborne diseases such as HIV and viral hepatitis, skin disorders, skin infections, and allergic reactions. In addition, persons with certain conditions including, but not limited to, diabetes, hemophilia or epilepsy, are at a higher risk for complications and should consult a physician before undergoing a body art procedure. If you wish to file a complaint against a body art facility related to compliance with PA 375 or have concerns about potential health risks, please visit www.michigan.gov/bodyart.

The answers provided by me were true and correct. If I reported one or more of the above conditions, I am advised to consult a physician before undergoing a body art procedure. I acknowledge that I have:

I understand that there is a non refundable deposit required for all tattoo procedures. We at Deadwood Ink understand that things do happen. Please reach out as soon as possible for any changes. A 24hr notice is required for appointment changes. Appointment changes cannot be made more than once for the same appointment (moving appointment dates and times)

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