STATE OF MISSOURI DIVISION OF PROFESSIONAL REGISTRATION PATRON CONSENT

STATE OF MISSOURI DIVISION OF PROFESSIONAL REGISTRATION PATRON CONSENT
SECTION I. PATRON'S INFORMATION
PATRON'S NAME (FIRST, MIDDLE, LAST) If patron is under the age of eighteen (18) parent or legal guardian's name shall also be provided.

First NameLast Name
PATRON'S DATE OF BIRTH

MonthDayYear
Date
PATRON'S ADDRESS (STREET, CITY, STATE, ZIP CODE)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PATRON'S RESIDENCE PHONE NUMBER
Format: (000) 000-0000.
PATRON'S DRIVER LICENSE NUMBER
PARENT OR LEGAL GUARDIAN'S DRIVER LICENSE NUMBER
PROCEDURE(S) TO BE PERFORMED (CHECK ALL THAT APPLY)
SECTION II. MEDICAL/HEALTH ASSESSMENT - QUESTIONS ARE TO BE ANSWERED BY THE PATRON.

SECTION II. MEDICAL/HEALTH ASSESSMENT - QUESTIONS ARE TO BE ANSWERED BY THE PATRON.

Rows	YES	NO
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 fights infections?

SECTION III. TO BE COMPLETED BY PATRON
I, , acknowledge that I am aware certain medical conditions and treatments and/or medications used to treat those medical conditions may be adversely impacted by the procedure(s) of tattooing and/or body piercing and/or branding. Such medical conditions include but are not limited to, impaired kidney and/or liver function, diabetes, jaundice, medication con- taining blood thinners and medications that weaken the immune system. I further acknowledge that the tattoo and/or brand should be considered permanent; that said tattoo and/or brand can only be removed with a surgical procedure; and that any effective removal may leave permanent scarring and disfigurement. I have read this form and confirm that all the information I have given is correct. I understand that this is a consent form and I agree to be legally bound by it.
SIGNATURE OF PATRON
DATE

MonthDayYear
Date
SIGNATURE OF PARENT/LEGAL GUARDIAN (IF PATRON IS UNDER THE AGE OF EIGHTEEN)
DATE

MonthDayYear
Date
SECTION IV. TO BE COMPLETED BY PRACTITIONER
I, , have reviewed this consent form and have advised the above named patron both in writing and verbally of the dangers and contradictions of the procedure that is to be performed.
SIGNATURE OF PRACTITIONER
LICENSE NUMBER
DATE

MonthDayYear
Date
MO 375-0200 (9-06)
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