Ink Ink Tattoos & Exotic Body Piercing Customer Record Form printable pdf download

Ink Ink Tattoos & Exotic Body Piercing Customer Record

****ALL TATTOOS AND PIERCINGS WILL BE PHOTOGRAPHED, NO EXCEPTIONS!!!****

NAME (LAST) __________________ (FIRST) _______________(MI) ____AGE _____

ADDRESS ______________________ CITY __________________________________

PHONE NUMBER __________________________TODAYS DATE _______________

D.O.B ___________________ RACE _______________________ SEX: Male / Female

EMAIL ADDRESS _______________________________________________________

EMERGENCY CONTACT __________________PHONE NUMBER ______________

ADDRESS ______________________________________________________________

PHYSICIANS NAME ______________________PHONE NUMBER_______________

ADDRESS ______________________________________________________________

A person may not perform a body piercing on a minor without written notarized

consent of the minor’s legal guardian. An establishment may not perform a body

piercing on a minor under the age of 16 unless legal guardian accompanies the minor.

MEDICAL SCREENING QUESTIONAIRE:

Please respond to each question by circling either - Yes / No

1. History of jaundice or hepatitis? Yes / No

2. History of aids or positive HIV tests? Yes / No

3. History of skin disease or skin cancer at the site of service? Yes / No

4. History of allergies or anaphylactic reaction to pigments dyes or other

sensitivities? Yes / No

5. History of hemophilia (bleeder)? Yes / No

6. History of diabetes? Yes / No

7. Currently taking medications which thin the blood and prevent clotting? Yes / No

8. Currently pregnant or under the influence of drugs or alcohol? Yes / No

9. History of any other known medical condition, which would influence or impair

the healing process? Yes / No

10. I have received and read all educational materials regarding my procedure and

have been informed of the procedure and understand the consequences of the

procedure which may include swelling, signs/ symptoms of infection, irritation,

pain, scarring/ deformity, or allergic reaction (see reverse side). Yes / No

11. “I have read and understand this sheet.” Yes / No (If no, explain)______________

__________________________________________________________________

______________________________

__________________________________

Customer Signature

Date

Legal Guardian Signature

Date

______________________________

__________________________________

Artist / Piercer Signature

Date

Artist/ Piercer Print Name

********************** Attach Copy of Drivers License **********************

Procedure Location_______________ Jewelry/ Tattoo Description__________________

Condition of Skin_____________Complications During Procedure__________________

________________________________________________________________________

Pigment Brand Used__________________Pigment Color Used_____________________

If you have any questions about your new tattoo/body piercing, please contact us:

INK INK Tattoos & Exotic body piercing

556 S. HWY 27 Suite D

Minneola, FL 34715

352-394-1882

Ink Ink Tattoos & Exotic Body Piercing Customer Record Form

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