Fillable Printable Written Notarized Consent For Tattooing

Written Notarized Consent For Tattooing

DH 4146 , 7/12

64E-28.009, F.A.C.

STATE OF FLORIDA

DEPARTMENT OF HEALTH

Authority 381.00789, Florida Statutes

WRITTEN NOTARIZED CONSENT FOR TATTOOING OF A MINOR CHILD,

AGE 16 THROUGH 17 YEARS OLD

State of Florida }

County of } Ss:

(Print Name of Parent or Legal Guardian)

Residing at:

HEREBY SWEARS OR AFFIRMS UNDER PENALTY OF PERJURY, that the

following facts as stated in this document are true:

1) I am the natural parent or legal guardian of:

(Print Name of Minor Child)

2) The Minor Child’s date of birth is:

(Month) (Day) (Year)

3) The child’s age is: .

4) I have the legal authority to give consent for this child’s Tattoo.

5) I consent to the tattooing of my child as follows: (description & location of Tattoo)

(Signature of Parent/Legal Guardian)

SWORN TO, OR AFFIRMED, IN PERSON BEFORE ME, this

day of

, 20 , by

(Print Name)

who is personally known to me, or, who produced satisfactory identification in the form of

Seal:

(Signature of Notary)

(Print Name of Notary)

For Office Use Only

(Printed Name of Licensed Salon)

(Signature of Tattoo Artist)

(Printed Name of Tattoo Artist)