Name *

First Name

Last Name

Today's Date *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Do you have any additional allergies to metals, soaps, cosmetics or alcohol? *

Yes

No

Do you use any medications that might affect the healing of the body art you wish to receive? *

Yes

No

Do you have a history of herpes or any other skin conditions that may affect the outcome of your procedure? *

Yes

No

Have you ever been prescribed antibiotics prior to dental or surgical procedures? *

Yes

No

INFORMED CONSENT TO RECEIVE 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 Black Lantern Art Collective, you confirm the following by checking each applicable item: NOTICE*: Tattoo inks, dyes, and pigments that have not been approved by the federal Food and Drug Administration have health consequences that are unknown.

I understand the implications and will complete each section to the best of my knowledge.

I am the person on the legal ID presented as proof that I am at least 18 years of age. *

Yes

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). *

Yes

No

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. *

Yes

I acknowledge that the information that I have provided in the medical questionnaire is complete and true to the best of my knowledge. *

Yes

I understand the permanent nature of receiving body art and that removal can be expensive and may leave scars on the procedure site. *

Yes

The body art described or shown on the client record form is correctly placed to my specifications. *

Yes

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. *

Yes

I understand the restrictions on physical activities such as bathing, recreational water activities, gardening, contact with animals, and the durations of the restrictions. *

Yes

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. *

Yes

I understand there is a possibility of getting an infection as a result of receiving body art and I will seek professional medical attention if signs and symptoms of infection occur. *

Yes

I understand that there is a chance I might feel lightheaded, dizzy during or after being tattooed. *

Yes

I agree to immediately notify the artist in the event I feel lightheaded, dizzy and/or faint before, during or after the procedure. *

Yes

I agree to and give Black Lantern Art Collective and my Tattoo Artist (mentioned above) permission to live stream, take videos, and take pictures of the work provided and allow the aforementioned parties to share them inter-personally and on social media platforms for promotion of their services. *

Yes

By Checking this Box I Agree *

I have been fully informed of the risks of body art 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 a body art procedure, I still wish to proceed with the body art application and I assume any and all risks that may arise from body art. I understand by checking this box I am providing the mutual assent required to form a legally binding agreement.

I Agree to All Terms and Conditions Listed Above