Fly Ink Tattoo Parlor
9220 Skillman Suite 211 Dallas, Texas 75243
Phone: 214-482-0156
Client Record /Contact - Medical History -/Consent Form FOR Body Piercing
PLEASE READ THE FOLLOWING NOTICE:
You are hereby notified of the possible risks and dangers associated with the application of each tattoo and receiving a body piercing(S). These risk and dangers include, but are not limited to, at least the following:
- The possibility of discomfort or pain;
- The permanence of the markings;
- The Possibility of scarring;
- The Possibility of bleeding;
- The Possibility of swelling;
- The risk of infection; and
The Possibility of nerve damage and - The increased risk for adolescents during certain stages of development.
- The possibility of allergic reaction to the pigments or other materials used.
NO PERSON MAY BE TATTOOED WHO APPEARS TO BE UNDER THE INFLUENCE OF ALCOHOL OR DRUGS.
Confidential Information Please, Check yes or no correctly and fill out all information that applies..
The rules state clients must present a valid, government issued, positive identification card, which includes a photograph and the date of birth.
Several types of identification commonly seen include a driver’s license, passport, military identification, and Department of Public Safety issued I.D. cards.
Client's Medical History: Confidentiality
Fill Only if Dependent Address is Different Above
Please provide Information and Verification of Proof of Dependent and Parent/Guardian
Body Piercing Parental Consent Affidavit
Under Penalty of Perjury, I the undersigned, declare the following [ Name of Child to Pierced ] is my minor child.
I have the authority to consent to body piercing on my child.
I have presented identification of myself and my minor child during the entire Body Piercing Procedure.
Date: 9/23/2020
Time: 7:39 PM
I acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions which I might have about the obtaining of a tattoo and that all of my questions have been answered to my full satisfaction. I specifically acknowledge I have been advised of the facts and matters set forth below and I agree as follows: PLEASE INITIAL BEHIND BULLETS BELOW
If I have any condition that might affect the healing of this tattoo, I will advise my tattooer. I am not pregnant or nursing. I am not under the influence of alcohol or drugs.
I do not have medical or skin conditions such as but not limited to: acne, scarring (Keloid) eczema, psoriasis, freckles, moles or sunburn in the area to be tattooed that may interfere with said tattoo. If I have any type of infection or rash anywhere on my body, I will advise my tattooer.
I acknowledge it is not reasonably possible for the representatives and employees of this tattoo shop to determine whether I might have an allergic reaction to the pigments or processes used in my tattoo, and I agree to accept the risk that such a reaction is possible.
I acknowledge that infection is always possible as a result of the obtaining of a tattoo, particularly in the event that I do not take proper care of my tattoo. I have received aftercare instructions and I agree to follow them while my tattoo is healing. I agree that any touch-up work needed, due to my own negligence, will be done at my own expense.
I realize that variations in color and design may exist between any tattoo as selected by me and as ultimately applied to my body. I understand that if my skin color is dark, the colors will not appear as bright as they do on light skin.
I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my tattoo.
I acknowledge that a tattoo is a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove my tattoo. To my knowledge, I do not have a physical, mental or medical impairment or disability which might affect my well being as a direct or indirect result of my decision to have a tattoo.
I acknowledge I am over the age of eighteen and that I have truthfully represented to my tattooer that the obtaining of a tattoo is by my choice alone. I consent to the application of the tattoo and to any actions or conduct of the representatives and employees of the tattoo shop reasonably necessary to perform the tattoo procedure.