Consent | Fine Line Tattoo SoCal

Consent to permanent body art application

NAME (as it appears in your legal ID)

Birthday

Month

Day

Year

Address

Phone Number

Today's Date

Month

Day

Year

The County of Riverside Department of Environmental Health requires all practitioners to keep a copy of their clients form of picture ID for the records. Please, upload a clear picture of your Driver's License, State ID, DOD ID or Passport for the records

I acknowledge that obtaining permanent body art is my choice alone. The application of permanent body art will result in a permanent change to my appearance, and that needles and inks will go into my skin. No representations have been made to me as the ability to restore the skin involved in permanent body art to the original condition, and it is very costly and/or not possible to remove.

I acknowledge that tattoo inks, dyes, and pigments have not been approved by the Federal Food and Drug Administration and that the health consequences of using these products are unknown.

I have truthfully represented to the Technician that I am 18 years of age or older. I am not under the influence of any drugs or alcohol. To my knowledge, I do not have any physical, mental, or medical impairment or disability that might affect my wellbeing as a direct or indirect result of my decision to have a tattoo or piercing at this time.

I acknowledge infection is always possible as a result of permanent body art application, and I agree to follow all suggested instructions concerning the care of the permanent body art site while it is healing.

I acknowledge that complications as a result of body art procedures may occur, such as ink drift, ink loss, uneven ink look, etc, particularly in the event that the post-procedural instructions are not followed and accept full responsibility for such complications.

I realize that my body is unique and neither the Technician nor their employees or contractors can predict how my skin may react or heal as a result of the procedure, nor its final look.

I understand that future skin altering procedures such as laser treatments, plastic surgery, implants, weight loss or gain,and/or injections may alter and degrade my body art piece, and that I must inform any future service provider that I have had body

art applied. I understand and accept that such changes are not the fault of the Technician or her employees or contractors. I further

understand that such changes or degradation in my appearance may not be correctable through further body art proce

I understand that I will have the opportunity, within the time constraints of my appointment, to approve the placement, design and color of the body art to be applied, and I accept responsibility for same.

I understand that I will have permanent body art applied using appropriate instruments and sterilization techniques. I understand that the permanent body art site usually takes 2 weeks or longer to heal. I agree to release and forever discharge, and hold harmless the Technician, all employees, contractors, and the management of the permanent body art studio from any and all claims of negligence, damages, or legal action arising from or connected in any way with my tattoo, piercing, the procedure

I understand that there are NO REFUNDS on services rendered, including all body art procedures done by the Technician and/or her employees or contractors. Should I not like the result of the body art procedure, right after being done or after healing, I understand that I am fully responsible for finding the best removal procedure for me and for covering the totality of its cost, with no exceptions.

Do you consent to the admittance of authorized observers to the procedure(s) for the purpose of education or assistance.

Yes

Do you give consent to this permanent body art studio to any relevant photographs and videos being taken both before and after the procedure, to document the results of the procedure. I consent to using "before & after" photos and videos?

Yes

Have you previously had permanent cosmetics or tattoo performed by someone other than Fine Line Tattoo SoCal on the same area, that you are asking to work on in this session

Yes, and I understand that correcting or touching up an existing body art piece that was performed by others involves additional risks because of the existence of permanent pigments or ink of unknown composition, brand, color, age, shape and other factors over which Fine Line Tattoo SoCal has no control. I understand that additional appointments may be required and charged separately from today.

I acknowledge that this is a contract and that I have received no warranties or guarantees with respect to the benefits to be realized from, or consequences of, the aforementioned procedure(s). I further acknowledge that at the time of signing this consent I am of sound mind and capable of making independent decisions for myself. I hereby release and forever discharge and hold harmless Fine Line Tattoo SoCal and its owners, managers, employees and affiliates from any and all claims, damages or legal actions arising from or connected in any way with my tattoo, piercing or the procedure and conduct used in my performing of body art service, to the fullest extent allowed by the law. Should I fail to comply, I understand that I will be brought to Small Claims Court and I will be responsible for any and every fee associated to the birch of this contract.

Are you currently in good health?

Yes

Do you have a phobia of needles?

Yes

Do you have a history of fainting?

Yes

Are you currently under a specialist doctor’s care? (If yes, please explain)

Do you take/use ANY medication, herbal/ natural supplements or topical creams on a regular basis? (if YES please name them)

Do you have or have you ever had ANY allergies to latex, antibiotics, medications, food, or other substances? (If YES, please explain)

Do you have high blood pressure?

Yes

Are you diabetic?

Yes

Do you have a history of herpes infection or any contagious medical condition at the proposed procedure site?

Yes

Do you have a history of hemophilia or other bleeding disorders?

Yes

Do you have a history of Keloid Scarring?

Yes

Do you suffer from cardiac valve disease?

Yes

Do you suffer with Acne, or have you taken medication for Acne in the past 6months?

Yes

Do you have ANY current or chronic medical illness, including: Myasthenia Gravis, Amyotrophic Lateral Sclerosis or any other neuromuscular disorders? (if YES please list)

Do you have an autoimmune disease? (If YES please list)

Do you have a history of medication use or are you currently on medication, including being prescribed antibiotics prior to dental or surgical procedures? (If YES please list)

16. Are there any risk factors for Bloodborne pathogen exposure? (if YES please list)

I am not pregnant or nursing a baby under 6 months of age. I do not have any history of herpes infections at the proposed procedure site. I do not have epilepsy, diabetes, allergic reactions to latex or antibiotics, hemophilia or other bleeding disorder. I do not have cardiac valve disease or suffer from any heart conditions or take medications that thin my blood.

If I suffer from hepatitis or other risk factors for blood borne pathogens exposure, or any other communicable disease, I have informed the Technician of the fact and have been advised of any medications and procedure necessary to promote the satisfactory healing of my tattoo or piercing.

I do not suffer from any medical or skin condition(s) such as, but not limited to: keloid or hypertrophic scarring, psoriasis at the site of permanent body art, or any open wounds or lesions at the site of the tattoo or piercing.

By signing BELOW, I acknowledge that I read and understand the contents of each statement above. I agree to paying the remaining balance, (TOTAL COST MINUS BOOKING FEE/s) is due in CASH at my appointment or be charged 8% of the total as a processing fee.

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