Name *

First Name

Last Name

Any changes in your Medical History? *

Yes

No

ELEVENTH DIMENSION TATTOO ARTS - TATTOO AFTERCARE INSTRUCTIONS *

The following verbal and/or written instructions were communicated to the client: 1. Information on the care of the procedure site. 2. Restrictions on physical activites such as bathing, recreational water activities, gardening, or contact with animals, and the duration of the restrictions. 3. 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. 4. Instructions to call a physician if any of the addressed signs and symptoms appear or for any other reason related to the Body Art procedure(s). 5. If physician care is required by the client related to the Body Art procedure(s), the client is to notify the Body Art facility and practitioner of the problem and the resolution by a physician or clinic. This information shall be placed in the client's file. By Checking this Box I Agree: I have been fully informed of the potential risks associated with a body art procedure including but not limited to infection, scarring, difficulties in detecting melanoma, and allergic reactions to tattoo pigment, latex gloves, and antibiotics. 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. For Additional Visits of Client: Aftercare has been re-explained and new instructions have been provided. No changes in medical history unless otherwise stated and informed consent.

I Agree to All Above Terms and Conditions