CONSENT FORM | L2 Ink

First name

Last name

Phone

Email

Address

Single choice

Driver’s License

Passport

Military ID

PRC (Green Card)

File upload

Date of Appointment:

Emergency contact:

Tattoo Description:

MEDICAL HISTORY

Do you have any additional allergies such as to metals, soaps, cosmetics, or alcohol?

YES

NO

Do you have any condition that requires you to take medications such as anticoagulants that thin the blood or interfere with blood clotting?

YES

NO

Do you have any other medical or skin conditions that might affect the outcome of this procedure?

YES

NO

Have you ever been prescribed antibiotics prior to dental or surgical procedures?

YES

NO

Do you have any cardiac valve diseases?

YES

NO

PLEASE READ AND SIGN WHEN YOU ARE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SIGNING.

I understand that the tattoo inks dyes, pigments have not been approved by the federal food and drug administration (FDA), and the health consequences of using these products are unknowns.

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 acknowledge the information I provided in the medical questionnaire is complete and true to the best of my knowledge.

The body art described or shown on this form is correctly placed to my specifications. If applicable, I have also confirmed all spelling and grammar necessary in the procedure.

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 associated with this body art procedure as explained by the technician.

I understand that any medical information obtained will be subject to the federal Health Insurance Portability and Accountability Act of 1996 (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 temperature, or purulent draining from the procedure site.

I understand there is a possibility of getting an infection as a result of receiving body art.

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 will be done at my own expense.

I understand that there is a chance that I might feel lightheaded or dizzy during or after being tattooed.

I agree to immediately notify the artist in the event I feel lightheaded, dizzy, and/or faint before, during or after the procedure.

I have knowledge of the permanent nature of body art (e.g., tattooing is permanent, and if you choose to have it removed, it may be expensive and leave scars.)

I will seek professional medical attention if signs and symptoms of infection occur.

I 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.

Date

Signature

BODY ART CONSENT AND HEALTH DISCLOSURE FORM