BODY ART CONSENT FORM
CLIENT INFO INFORMED CONSENT TO RECEIVE BODY ART
PLEASE READ AND CHECK THE BOXES WHEN YOU ARE CERTAIN YOU
Name:______ ________________ Date: _____________
UNDERSTAND THE IMPLICATIONS OF SIGNING
Address: _______________________________________________________ In consideration of receiving BODY ART from , ________________________
(Name of the Practitioner)
Phone number: _____________________ Date of Birth: _________________ the practitioner at ______________________ (together with its employees,
(Name of Body Art Business)
apprentices, and agents, the “Body Art Business”)
Email:__________________________________________________________
I _______________confirm the following by initialing each applicable item:
Emergency contact: _________________ Phone: ______________________ (Client’s Name)
Type of Identification Provided: NOTICE*: Tattoo inks, dyes, and pigments that have not been approved by
the federal Food and Drug Administration have health consequences that are
Drivers License Passport Birth Certificate unknown.
______ I am the person on the legal ID presented as proof that I am at least
Apply a check to the type of body art being performed: 18 years of age.
Permanent ______ I am under the age of 18 years old and have the presence of my
Tattoo Branding Piercing parent or guardian to receive the body piercing. (Applicable only to
cosmetics
underage body piercing. N/A if not applicable).
______ I am not under the influence of alcohol or drugs and that I am
Procedure Site: Description of Procedure: voluntarily submitting myself to receive body art without duress or coercion.
______ I acknowledge that the information that I have provided in the
medical questionnaire is complete and true to the best of my knowledge.
______ I understand the permanent nature of receiving body art and that
removal can be expensive and may leave scars on the procedure site.
______ The body art described or shown on the client record form is
correctly placed to my specifications.
______ All questions about the body art procedure have been answered to
MEDICAL HISTORY my satisfaction, and I have been given written aftercare instructions for the
Please circle any conditions listed below that apply to you. procedure I am about to receive.
______ I understand the restrictions on physical activities such as bathing,
TB Asthma Eczema/Psoriasis Gonorrhea recreational water activities, gardening, contact with animals, and the
durations of the restrictions.
HIV Hepatitis Heart Conditions Syphilis ______ I understand that any medical information obtained will be subject to
Skin MRSA/Staph the federal Health Insurance Portability and Accountability Act of 1996
Herpes Pregnant/Nursing (HIPPA).
Conditions Infections
Blood ______ *I am aware that tattoo inks, dyes, and pigments used on the
Diabetes Fainting/Dizziness Latex Allergies procedure site have not been approved by the federal Food and Drug
Thinners
Administration, and that the health consequences of using these products
Antibiotic
Epilepsy Hemophilia Scarring/Keloiding are unknown.
Allergies
______ 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 drainage from the procedure site.
______ I understand there is a possibility of getting an infection as a result of
Do you have any additional allergies such as to metals, soaps, cosmetics or receiving body art particularly in the event that I do not take proper care of
alcohol? the procedure site.
______ I will seek professional medical attention if signs and symptoms of
Do you use any medications that might affect the healing of the body art you infection occur.
wish to receive? ______ I agree to follow all instructions concerning the care of my tattoo,
and that any touch-ups needed due to my own negligence will be done at my
Do you have a history of herpes at the procedure site? own expense.
______ I understand that there is a chance I might feel lightheaded, dizzy
Do you have any other medical or skin conditions that affect the outcome of during or after being tattooed.
your procedure? ______ I agree to immediately notify the artist in the event I feel
lightheaded, dizzy and/or faint before, during or after the procedure.
Have you ever been prescribed antibiotics prior to dental or surgical
procedures? I, ____________________________________(print name) have been fully
informed of the risks of body art including but not limited to infection,
Do you have any cardiac valve disease? scarring, difficulties in detecting melanoma, and allergic reactions to tattoo
pigment, latex gloves, and antibiotics. Having been informed of the potential
risks associated with a body art procedure, I still wish to proceed with the
Is there any information you feel you should provide to the body art
body art application and I assume any and all risks that may arise from body
practitioner?
art.
Other medical conditions? Signature of Client: _____________________________Date: ___________
Signature of Practitioner: ________________________ Date: ___________
SWP-152 8/15/17
INSTRUMENT LOG
If single-use, pre-packaged, pre-sterilized instruments and needles are used please maintain the following records:
(1) A record of purchase and use of all single-use instruments.
(2) A log of all procedures, including the names of the practitioner and client and the date of the procedure.
(3) Written proof on company or laboratory letterhead showing that the presterilized instruments have undergone a sterilization process. Written proof shall
clearly identify the instruments sterilized by name or item number and shall identify the lot or batch number of the sterilizer run.
Supplier Instrument/Needle Lot/ID # Sterilization Date Expiration Invoice Number
AFTERCARE INSTRUCTIONS
CLIENT NAME: ________________________________________________________
The following verbal and/or written instructions were communicated to the client:
1. Information on the care of the procedure site.
2. Restrictions on physical activities such as bathing, recreational water activities, gardening, or contact with animals, and the duration of the restrictions.
3. 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 temperature, or purulent drainage from the procedure site.
4. Instructions to call a physician if any of the addressed signs and symptoms appear or for any other reason related to the Body Art procedure(s).
5. If physician care is required by the client related to the Body Art procedure(s), the client is to notify the Body Art facility and practitioner of the problem and the
resolution by a physician or clinic. This information shall be placed in the client’s file.
COMMENTS:
To the best of my knowledge this information is correct:
Practitioner Signature: ________________________ Date: _____________
I have received aftercare instructions:
Client Signature: _____________________________ Date: _____________
SWP-152 8/15/17
