Body Art Client Consent Form

Body Art Client Consent Form
Name*

First NameLast Name
Age*
Age
Birthdate*

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Would you like to be added to our email list for special discounts?

YesNo
How did you hear about us?

Client Consent

Please read and initial the boxes below to confirm the information is understood.
I am the person on the legal ID presented as proof that I am at least 18 years of age*
I am not under the influence of alcohol or drugs and that I am voluntarily submitting myself to receive body art without duress or coercion.*
I understand the permanent nature of receiving body art and that removal can be expensive and may leave scars on the procedure site*
All questions about the body art procedure have been answered to my satisfaction, and I have been given written aftercare instructions for the procedure I am about to receive.*
I understand the restrictions on physical activity such as bathing, recreational water activities, gardening, contact with animals, and the durations of the restrictions.*
I understand there is a possibility of getting an infection and I am aware of the signs and symptoms, including, but not limited to redness, swelling, tenderness of the procedure site, red streaks going from the procedure site toward the heart, elevated body temperature, or purulent drainage from the procedure site.
I understand there is a chance I might feel lightheaded, dizzy during or after being tattooed. I will notify the artist immediately if this occurs.*
HIPAA REQUIREMENTS: Any medical information obtained will be subject to the Health Insurance Portability and Accountability Act of 1996 (HIPPA).

TATTOO INKS: Tattoo inks, dyes, and pigments that have not been approved by the Federal Food and Drug Administration have health consequences that are unknown.

I acknowlege that the information that I have provided is true to the best of my knowledge. I have been fully informed of the potential risks associated with a body art procedure. I still wish to proceed with the body art application and assume any and all risks that may arise from body art. Aftercare has been explained and the instructions have been provided.
Client Signature*
Should be Empty:

Body Art Client Consent Form

Medical History

Please note, we cannot perform this service if you are pregnant.

Client Consent