1 - Patron Consent Form - John Monk's Revelation Tattoo

Section One: Patron's Information

PATRON'S NAME (First, Middle, Last)*

Patron is over the age of Eighteen (18).

First Middle Last

Patron's Driver's License Number

Patron's Driver's License Number*

PROCEDURE(S) TO BE PREFORMED (check all that apply)*

TATTOO
BODY PIERCING

Part of the body to be Pierced*

Section Two: Medical / Health Assessment Questions are to be answered by the Patron

Are you currently or have you ever used medications that contain a controlled substance?*

YES
NO

Have you ever been diagnosed by a medical doctor as to having contracted communicable disease such as Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and/or other blood borne pathogens? If so, when?*

YES
NO

If so, when?*

Have you ever been diagnosed by a medical doctor as having allergies?*

YES
NO

Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*

YES
NO

Are you currently under the influence of any illegal substances?*

YES
NO

Are you currently under the influence of an alcoholic beverage?*

YES
NO

Have you been diagnosed with jaundice within the past twelve months?*

YES
NO

Are you currently using any medications that contain blood thinners?*

YES
NO

Are you currently using any medications that weaken the immune system that fights infections?*

YES
NO

Section Three: To be completed by Patron

Patron Name*

Patron Consent*

I, above listed Patron, acknowledge that I am aware certain medical conditions and treatments and/or medications used to treat those medical conditions may be adversely impacted by the procedure(s) of tattooing and/or body piercing and/or branding. Such medical conditions include but are not limited to, impaired kidney and/or liver function, diabetes, jaundice, medication containing blood thinners and medications that weaken the immune system. I further acknowledge that the tattoo and/or brand should be considered permanent; that said tattoo and/or brand can only be removed with a surgical procedure; and that any effective removal may leave permanent scarring and disfigurement. I have read this form and confirm that all the information I have given is correct. I understand that this is a consent form and I agree to be legally bound by it.

Patron Signature*

Date*

STOP HERE let us know you have completed your portion of the consent form.

Section Four: TO BE COMPLETED BY PRACTITIONER

Practitioner Name*

Practitioner Consent*

I, above listed Practitioner, have reviewed this consent form and have advised the above named patron both in writing and verbally of the dangers and contradictions of the procedure that is to be performed.

Practitioner Signature*

License Number*

Date*

1 – Patron Consent Form