CLIENT BODY ART RECORD & TATTOO CONSENT
Berry Park Fine Line Tattoo
Tattoo Artist: Seryna Valencia
Address:
1604 4 Mile Rd NE, Suite 105, Grand Rapids, MI 49525
CLIENT / PROCEDURE INFORMATION
Client name:
*
First Name
Last Name
Birthday:
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone:
*
Format: (000) 000-0000.
Email:
*
example@example.com
Procedure date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Tattoo design/description:
Body location:
Client contact information may be used for a communicable disease outbreak investigation, recall, or other issue pertaining to the client's health.
HEALTH QUESTIONNAIRE - CHECK YES OR NO
History of hemophilia or excessive bleeding
Yes
No
History of skin disease, skin lesions, or skin sensitivities to soaps or disinfectants
Yes
No
Allergies/adverse reactions to latex, pigments, dyes, disinfectants, metals, or other body-art related sensitivities
Yes
No
History of epilepsy, seizures, fainting, or narcolepsy
Yes
No
Treatment with anticoagulants or other medications that thin the blood and/or interfere with blood clotting
Yes
No
Diabetes or other conditions which may affect blood circulation and/or ability to fight infection
Yes
No
Current pregnancy and/or breastfeeding
Yes
No
Did you use any numbing cream today?
Yes
No
Any other condition, medication, allergy, or information relevant to suitability for tattooing or healing
Yes
No
If YES to any item, explain:
If you report one or more of the conditions above, you are encouraged to consult your physician before undergoing a body art procedure.
REQUIRED ACKNOWLEDGMENTS & INFORMED CONSENT
I received a copy of the Disclosure Statement / Notice for Filing Complaints.
I received a copy of the Tattoo Aftercare Information Sheet.
I completed the Client Health Questionnaire and received any additional applicable information.
I voluntarily consent to the tattoo procedure described above and certify that the information I provided is true and correct to the best of my knowledge.
Picture of the front of your ID
*
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2 digit month, 2 digit day, 4 digit year
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Artist Signature:
Date:
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2 digit month, 2 digit day, 4 digit year
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