Fillable Printable Client Questionnare and Consent Form for Body Art
Fillable Printable Client Questionnare and Consent Form for Body Art
Client Questionnare and Consent Form for Body Art
CLIENT QUESTIONNAIRE AND CONSENT FORM FOR BODY ART
Before a body art procedure begins, the body artist shall obtain pertinent records and an informed consent from
the client. This information shall be obtained in a Client Questionnaire and Consent Form.
A Client Questionnaire and Consent Form may include a client records form; medical history questionnaire and
informed consent form to perform body art and will be considered confidential information. All information
gathered from the client that is personal medical information and that is subject to the federal Health Insurance
Portability and Accountability Act of 1996 (HIPPA) or similar state laws shall be maintained or disposed of in
compliance with those provisions.
The shop permit holder is obligated to maintain proper records for each customer. The records shall include the
following:
1.
The date of the procedure.
2.
Record of information on a picture identification showing name, age and current address of client.
3.
The description of the procedure. This includes the design and location of the tattoo, permanent
cosmetics, branding, or body piercing.
4.
The name and registration number of the tattooist, permanent cosmetic technician, branding, or
body piercer.
5.
Copy of the signed Client Questionnaire and Consent Form to perform the tattoo, permanent
cosmetic, branding, or body piercing procedures.
Included with this cover letter is a Client Questionnaire and Consent Form template. The Kern County
Environmental Health Division recommends that all body art facility owners use this template as a guide to
develop forms that will be specific in obtaining records beneficial in protecting the health and safety of all
potential clients.
If you have any questions, please contact the Kern County Environmental Health Division, Body Art Program
at (661) 862-8740.
CLIENT RECORDS
NAME: ___________________________________DATE: _______________________
ADDRESS: _______________________________________________________________________________
Apply a check to the type of body art being performed:
TATTOO_____ PERMANENT COSMETICS_____ BRANDING_____ PIERCING_____
COPY OR DESCRIPTION OF PROCEDURE
DATE OF BIRTH
PROCEDURE SITE OF
BODY ART
NAME AND
REGISTRATION # OF
PRACTITIONER
I accept this design.
Client Signature: ________________________________________________________________________
Phone Number: _________________________________________________________________________
ID of Client
ID of Parent or Guardian
(Applicable only to underage body piercing)
MEDICAL HISTORY QUESTIONNAIRE
Name: ____________________________________________________________________________________
Last First Middle
Date of Birth: _________________________________________________ Sex: _______________________
Address: __________________________________________________________________________________
Emergency Contact: _________________________________________ Phone: (______)__________________
Please check any conditions listed below that apply to you.
______ ALLERGIC TO ANTIBIOTICS _____ EPILEPSY ______ HERPES
______ ALLERGIC TO LATEX _____ FAINTING OR DIZZINESS ______ HIV
______ ASTHMA _____ GONORRHEA/SYPHILIS ______ MRSA/STAPH INFECTION
______ BLOOD THINNERS _____ HEART CONDITION ______ PREGNANT/NURSING
______ DIABETES _____ HEMOPHILIA ______ SCARRING/KELOIDING
______ ECZEMA/PSORIASIS _____ HEPATITIS ______ SKIN CONDITIONS
_____ OTHER*
*If you checked other, please state the condition.
__________________________________________________________________________________________
How long has it been since you last ate?
__________________________________________________________________________________________
Do you have any allergies such as metals, soaps, cosmetics or alcohol?
__________________________________________________________________________________________
Do you use any medications that might affect the healing of the body art you wish to receive?
__________________________________________________________________________________________
Do you have any other medical or skin conditions that may affect the outcome of your procedure?
__________________________________________________________________________________________
Have you ever been prescribed antibiotics prior to dental or surgical procedures?
Do you have any cardiac valve disease?
__________________________________________________________________________________________
Is there any other information you feel you should provide to the body art practitioner?
__________________________________________________________________________________________
The information I have provided is complete and true to the best of my knowledge.
Signature of Client: ___________________________________________ Date: _______________________
INFORMED CONSENT TO BODY ART
PLEASE READ AND CHECK THE BOXES WHEN YOU ARE CERTAIN YOU UNDERSTAND
THE IMPLICATIONS OF SIGNING
In consideration of receiving BODY ART from _______________________________, the practitioner at
(Name of the Practitioner)
_____________________, (together with its employees, apprentices, and agents, the “Body Art Business”)
(Name of Tattoo Business)
I _________________________________________confirm the following by initialing each applicable item:
(Client’s Name)
*CAUTION: Tattoo inks, dyes, and pigments that have not been approved by the federal Food and Drug Administration
have health consequences that are unknown.
I am the person on the legal ID presented as proof that I am at least 18 years of age.
I am under the age of 18 years old and have the presence of my parent or guardian to receive the body piercing
(Applicable only to underage body piercing. N/A if not applicable).
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 that the information that I have provided in the medical questionnaire is complete and true to the
best of my knowledge.
I understand the permanent nature of receiving body art and that removal can be expensive and may leave scars
on the procedure site.
The body art described or shown on the client record form is correctly placed to my specifications.
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 on physical activities such as bathing, recreational water activities, gardening, contact
with animals, and the durations of the restrictions.
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 that tattoo inks, dyes, and pigments used on the procedure site have not been approved by the federal
Food and Drug Administration, and that the health consequences of using these products are unknown.
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 drainage from the procedure site.
I understand there is a possibility of getting an infection as a result of receiving body art particularly in the event
that I do not take proper care of the procedure site.
I will seek professional medical attention if signs and symptoms of infection occur.
I agree to follow all instructions concerning the care of my tattoo, 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 I might feel lightheaded, 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 agree to release and forever discharge and forever hold harmless _______________________ and its associates,
agents, officers, and shareholders from any and all claims, damages, or legal actions arising from or connected in
any way with my body art or the procedures and conduct used to apply my body art and any and all body art
applied by _______________________ and its associates, agents and representative in the future.
I, ______________________________________________have been fully informed of the risks of tattooing including
but not limited to infection, scarring, difficulties in detecting melanoma, and allergic reactions to tattoo pigment, latex
gloves, and antibiotics. Having been informed of the potential risks associated with getting a tattoo, I still wish to
proceed with tattoo application and I assume any and all risks that may arise from tattooing.
Signed: ___________________________________________________ Date: __________________________
If single-use pre-sterilized equipment is used please provide Lot/ID number.
Artist: _________________________________________Lot/ID#:___________________________________
