BODY ART CONSENT AND HEALTH DISCLOSURE FORM for TATTOOING AND PIERCING

CLIENT INFO INFORMED CONSENT TO RECEIVE BODY ART

Name: PLEASE READ AND SIGN WHEN YOU ARE CERTAIN YOU
Date of Date of UNDERSTAND THE IMPLICATIONS OF SIGNING.
Procedure: Birth:
In consideration of receiving BODY ART from,
Address: (Name of Technician)

The practitioner at
Phone: (Name of body art establishment)

(together with its employees and other technicians, the “Establishment”)

Email: I confirm the following by initialing
Emergency (Client’s Name)

Contact: Phone: each applicable item below:

Type of Identification Provided: I understand that a tattoo is considered permanent and may only be
removed with a surgical procedure.
Driver’s License Passport Tribal ID Card
I understand that any effective removal of a tattoo or body piercing
may leave scarring.
Military ID Permanent Resident Card (Green Card)
I am the person on the legal ID presented as proof that I am at least 18
years of age.
Circle the type of body art being performed:
I am under the age of 18 years old and have the presence of my parent
Tattoo Branding Piercing Scarification or guardian to receive the body piercing (applicable only to underage
body piercing. N/A if not applicable).
Tongue I am not under the influence of alcohol or drugs and that I am
Subdermal Microdermal Suspension
Bifurcation voluntarily submitting myself to receive body art without duress or
coercion.
Procedure Site/Description:
I acknowledge the information I provided in the medical questionnaire
is complete and true to the best of my knowledge.
Technician: License #: The body art described or shown on this form is correctly placed to my
specifications. If applicable, I have also confirmed all spelling and
MEDICAL HISTORY grammar necessary in the procedure.
Please circle any conditions listed below that apply to you:
All questions about the body art procedure have been answered to my
Diabetes Hemophilia Skin disease (psoriasis, eczema, etc.) satisfaction, and I have been given written aftercare instructions for the
procedure I am about to receive.
Skin lesions Skin sensitivity to soap or disinfectant Epilepsy I understand the restrictions associated with this body art procedure as
explained by the technician.
Seizures Fainting Narcolepsy
I understand that any medical information obtained will be subject to
the federal Health Insurance Portability and Accountability Act of 1996
Additional health information: (HIPPA).
I am aware of the signs and symptoms of infection, including but not
limited to, redness, swelling, tenderness of the procedure site, red
streaks going from the procedure site towards the heart, elevated body
How long has it been since you last ate? temperature, or purulent draining from the procedure site.
Do you have any additional allergies such as to metals, I understand there is a possibility of getting an infection as a result of
YES NO
soaps, cosmetics, or alcohol? receiving body art.
Do you have any condition that requires you to take I will seek professional medical attention if signs and symptoms of
medications such as anticoagulants that thin the blood YES NO infection occur.
or interfere with blood clotting? I agree to follow all instructions concerning the care of my body art
procedure and that any touch-ups needed due to my own negligence
Have you ever been prescribed antibiotics prior to
YES NO will be done at my own expense.
dental or surgical procedures?
I understand that there is a chance that I might feel lightheaded or dizzy
Do you have any other medical or skin conditions that during or after being tattooed.
YES NO
might affect the outcome of this procedure?
I agree to immediately notify the artist in the event I feel lightheaded,
dizzy, and/or faint before, during or after the procedure.
Do you have any cardiac valve diseases? YES NO

I, _____________________________________ (print name) have been fully informed of the risks of body art including but not limited to infection, scarring, and
allergic reactions to items associated with body art procedures. Technician will not perform the body art procedure if you fail to complete or sign this form. Further,
technician may decline to perform a body art procedure if the client has any identified health conditions. Having been informed of the potential risks associated with
this body art procedure, I still wish to proceed with the body art application and I assume any/all risks that may arise from body art.
Client Signature Date:
Technician Signature Date: