Client Body Art Record And Consent Form - State Of Michigan printable pdf download

License Number: _____________________________________

Client Body Art Record and Consent Form

If the client is a minor, the following must be included in the file:

 Proof of parental or legal guardian identification in the form of a photo identification. Acceptable forms of ID include a driver’s

license, a passport, or state or government-issued identification that includes the parent’s or legal guardian’s name, picture and

date of birth.

 A copy of the minor’s birth certificate and/or court document verifying the parent’s or legal guardian’s relationship with the

minor.

Note: The minor’s parent or legal guardian must execute the written informed consent in the presence of the body art technician

performing the body art procedure or another individual working in the body art facility.

Client Health Questionnaire

Before starting a body art procedure, each person seeking a tattoo, branding or body piercing shall be asked about the following

conditions:

 History of hemophilia or excessive bleeding

 Diabetes or other conditions which may affect blood circulation and/or ability to fight infection.

 History of skin disease, skin lesions, or skin sensitivities to soaps or disinfectants

 History of allergies or adverse reactions to latex, pigments, dyes, disinfectants, metals or other sensitivities related to body art

procedures

 History of epilepsy, seizures, fainting or narcolepsy

 Treatment with anticoagulants or other medications that thin the blood and/or interfere with blood clotting

 Current pregnancy and/or breast-feeding

 Any other information that would aid the body art technician or any other individual involved in providing education on the

client’s suitability for receiving a body art procedure and the client’s body healing process

Any client reporting one or more of the above conditions should be encouraged to consult their physician before undergoing a body art

procedure.

Indicate by checking the box that the client has:

 Received a copy of the Disclosure Statement and Notice for Filing Complaints

 Received a copy of the Aftercare Information Sheet

 Completed the Client Health Questionnaire, and received any additional, applicable information

Client Consent

I acknowledge that I have received a copy of the Disclosure Statement and Notice for Filing Complaints, received a copy of the

Aftercare Information Sheet, and completed the Client Health Questionnaire and received any additional, applicable information.

In addition, this record serves as signed documentation that the body art facility performing your tattoo, piercing, and/or branding is a

licensed facility by the State of Michigan. It is recommended that individuals or organizations visit

determine current the license status of the body art facility before proceeding with any body art procedure.

___________________________________________________________________

__________________

Client/Parent/Legal Guardian Signature

Date

Date of Body Art Procedure:____________________

Name of body art technician performing the body art procedure: _____________________________________________

Client’s Name:___________________________________________________________

Address:____________________________________________________________________________________________________

____________________________________________________________________________________________________

Age/Date of Birth:________________________________________________________

Client Contact Information

(used only in the event of a communicable disease outbreak investigation or other issues pertaining to client’s health)

Telephone:

(______)______-__________

E-mail Address: _____________________________

Client Body Art Record And Consent Form - State Of Michigan

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