PIERCING CONSENT RELEASE FORM PLEASE READ AND CHECK THE BOXES WHEN YOU ARE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SIGNING THIS DOCUMENT
|
|
|
- Diane Potter
- 6 years ago
- Views:
Transcription
1 PIERCING CONSENT RELEASE FORM PLEASE READ AND CHECK THE BOXES WHEN YOU ARE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SIGNING THIS DOCUMENT In consideration of receiving piercing from (Name of Practitioner) located at. (Name of Body Art Business), the practitioner I confirm the following: All questions about the body piercing procedure have been answered to my satisfaction, and I have been given written aftercare instructions for the body piercing I am about to receive. I have been informed about what I can expect following the body piercing listed on the informed body piercing consent form, including medical complications that may occur following this body piercing. I understand that body piercing can result in nerve damage, bone and tooth loss, and that if I choose to remove my jewelry, permanent holes or scars may be left. I am the person on the legal ID presented as proof that I am at least 18 years of age, or the body piercing will be performed in the presence of my parent or legal guardian. I am not under the influence of alcohol or drugs and that I am voluntarily submitting to body piercing without duress or coercion. I understand there is a possibility of an allergic reaction to the jewelry inserted into the fresh body piercing. I understand there is a possibility of getting an infection, and I have been advised of the signs and symptoms of infection that indicate a need to seek medical attention. I agree to follow all instructions concerning the care of my body piercing. I understand that there is a chance I might feel lightheaded or dizzy during or after being pierced. I agree to immediately notify the body piercer in the event I feel lightheaded, dizzy and/or faint before, during or after the procedure I, have been fully informed of the risks of body piercing including but not limited to infection and other medical complications, allergic reactions to metal jewelry, latex gloves, and antibiotics. Having been informed of the potential risks associated with receiving a body piercing, and I still wish to proceed with the procedure. I assume any and all risks that may arise from the body piercing. Signature: Date: Procedure description: Artist:
2 TATTOO CONSENT RELEASE FORM I acknowledge by signing this release form that I have been given the full opportunity to ask any and all questions I might have about obtaining a tattoo from. I acknowledge that all my questions have been answered to my full and total satisfaction. I specifically acknowledge that I have been advised of the facts and matters set forth below, and I agree as follows: I am not under the influence of alcohol or drugs. I do not have acne, freckles, moles, or sunburn in the area to be tattooed that might be agitated by the tattoo process (healing excluded). I have looked over my design, checked the spelling if applicable, and give my full consent to the application of my tattoo. I acknowledge that I am not pregnant. I acknowledge that I am free of communicable disease. I acknowledge that I have truthfully represented to the associates, agents and representatives of that I am over eighteen (18) years of age. I acknowledge it is not reasonably possible for the associates, agents and representatives of to determine whether I might have an allergic reaction to the dyes, pigments, or processes used in my tattoo and I agree to accept that such risks are possible. I acknowledge that infection is always possible as a result of obtaining a tattoo particularly in that event that I do not take proper care of my tattoo, and I have been advised of the signs and symptoms of infection that indicate a need to seek medical care. I acknowledge receipt of written instructions advising me of proper care of my tattoo and recognize the absolute necessity of following those written instructions. All questions about the body art procedure have been answered to my satisfaction. I acknowledge that variations in color and design may exist between any tattoos as selected by me and as ultimately applied to my body. I acknowledge that tattooing is a permanent change to my appearance and that no representations have been made to me as to the ability to later change, alter or remove my tattoo. I acknowledge that the obtaining of my tattoo is my choice alone and I consent to the application of the tattoo and to any actions or conduct of the associates, agents or representatives of that are reasonable necessary to perform the tattoo 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 tattoo or the procedures and conduct used to apply my tattoo and any and all tattoos applied by and its associates, agents and representatives in the future. I acknowledge that tattoo inks, dyes and pigments have not been approved by the federal Food and Drug Administration and the health consequences of using these products are unknown. I acknowledge that there is a chance I might feel lightheaded, dizzy during or after being tattooed. I agree to immediately notify the practitioner in the event I feel lightheaded, dizzy and/or faint before, during or after the procedure. I agree to follow all instructions concerning the care of my tattoo, and that any touch-ups needed because of my own negligence will be done at my own expense. 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. Signature: Procedure description: Artist: Date:
3 PARENTAL PIERCING/TATTOO CONSENT RELEASE FORM I acknowledge by signing this release form that I hereby release and its employees and agents from all manner of liabilities, claims, actions, and demands, in law or in equity, which I or my heirs have or might have now or hereafter by reason of complying with my request to pierce by child. I certify that I am the parent or legal guardian of the minor receiving the piercing and/or tattoo. I agree that I will assume all responsibility for any medical, legal, or other situation resulting from my request to pierce/tattoo my child. I understand that I must remain in the presence of this minor during piercing/tattooing procedures. I understand that my child will be pierced/tattooed using appropriate instruments and techniques. I understand that this type of piercing usually takes or longer to heal. I have signed this release on, 20.. Adult s relation to Minor: Attach copies of ID for both the minor and parent/guardian to this form. Explain the manner in which the procedure will be performed and the specific part of the body upon which the procedure will be performed: I certify under penalty of perjury that the information herein is true and correct. Adult s Signature: Minor s Signature:
4 Client Record Last Name: First Name: Address: City: State: Zip: Date of Birth: Parental Consent: Yes NA Date: PLEASE CIRCLE ANY CONDITIONS LISTED BELOW THAT APPLY TO YOU TB EPILEPSY BLOOD THINNERS SCARRING/KELOIDING HIV ASTHMA ECZEMA/PSORIASIS GONORRHEA/SYPHILIS HEPATITIS HEART CONDITION MRSA/STAPH INFECTIONS HERPES HEMOPHILIA/OTHER BLEEDING DISORDER PREGNANT/NURSING ALLERGIC REACTIONS TO LATEX DIABETES SKIN CONDITIONS FAINTING OR DIZZINESS ALLERGIC REACTIONS TO ANTIBIOTICS How long has it been since you last ate? Do you have any allergies? Do you use any medications or have any medical/skin conditions that may affect the healing of the body art you wish to receive? Is there any information you feel you should provide to the body artist? PROCEDURE: Tattoo Location of tattoo: Colors, Manufacturer, and Lot Numbers of all inks used: Piercing Location of piercing: Jewelry used including size, material composition, and manufacturer: Body Artist Signature: Client Signature: Attach to this page copies of clients ID and any packaging showing lot numbers, date sterilized, etc. from all instruments or equipment used during this procedure.
5 Date Load # Contents Operator Time Weekly Biological Indicator? Results Pass/Fail Attach Sterilization Integrator
6 IPCP Training Documentation By signing below the attendee certifies that they have been trained on and understand all policies, procedures, and requirements of the Infection Prevention and Control Plan for the following tattoo and/or body piercing establishment: Date Name of Attendee Signature of Attendee Instructor
7 Employee Training ARTIST NAME DATE HIRED FIRST AID EXPIRES BLOODBORNE EXPIRES Date No Longer Employed
APPLICANT/BODY ART ESTABLISHMENT PERMIT STATEMENT OF CONSENT
9. Provide the Following With Application: A. (New & Renewal Applications) Present original and provide copy of Business Certificate issued by the Everett City Clerk under provisions ofmgl c. 110 subsection
TATTOOING, BODY PIERCING, PERMANENT COSMETICS & BRANDING APPLICATION FOR REGISTRATION
TATTOOING, BODY PIERCING, PERMANENT COSMETICS & BRANDING APPLICATION FOR REGISTRATION 1. GENERAL PRACTITIONER INFORMATION New Registration Annual Registration Updated Registration FULL LEGAL NAME (Give
SUTTER COUNTY DEVELOPMENT SERVICES DEPARTMENT
SUTTER COUNTY DEVELOPMENT SERVICES DEPARTMENT Building Inspection Planning Fire Services Road Maintenance Code Enforcement Environmental Health Engineering Water Resources SUMMARY OF THE SAFE BODY ART
513 Maple Ave West, Vienna, VA
CLIENT INFORMATION AND CONSENT FORM: SKIN CARE Name Date of Consultation Address City State Zip Home phone ( ) Cellular phone ( ) E-mail Date of birth Emergency contact and telephone number How did you
Brow and Beauty Bar - Permanent Makeup
General Consent and Procedure Permit Clients Full Name Mr/Mrs/Miss/Ms Address e-mail I hereby authorize Erin Exline to perform upon myself permanent cosmetic enhancement. If any unforeseen condition arises
Pre-Treatment Advice and Procedures
1 Client copy Pre-Treatment Advice and Procedures Since delicate skin or sensitive areas may swell slightly, or redden, it is advised not to make social plans for the same day. Lip liner may appear "crusty"
Medication Name Reason Taken Dosage Last Date Taken
CLIENT HISTORY FORM Print Name Location of Service: Email Birth Date Age Gender @ Female Address City State / Male Emergency Contact Name and Number Home Phone ( ) Cell Phone ( ) Today s Procedure Description:
Pre-Treatment Advice and Procedures
Pre-Treatment Advice and Procedures 1) Since delicate skin or sensitive areas may swell slightly, or redden, it is advised not to make social plans for the same day. Lip liner may appear crusty for up
Permanent Makeup Intake Form
Permanent Makeup Intake Form Artist Information (the Artist ): Chrystal Ladouceur 1530 McTavish Road, North Saanich, B.C., V8L 5T3 Client Information (the Client ): First Name Email Mobile Phone Address
Pre Treatment Advice and Procedures
Pre Treatment Advice and Procedures 1. Since delicate skin or sensitive areas may swell slightly, or redden, it is advised not to make social plans for the same day. Lip liner may appear crusty for up
VICKI HENKE MICROBLADING PERMANENT COSMETICS. What to expect in the healing process for all brow enhancement/permanent makeup procedures.
MICROBLADING/MANUAL PERMANENT MAKEUP TREATMENT BEFORE & AFTER CARE INSTURCTIONS What to expect in the healing process for all brow enhancement/permanent makeup procedures. WHILE YOUR SKIN HEALS, BE PREPARED
Touch Up-Color Refresh Policy
Touch Up-Color Refresh Policy All Full Price New Procedures clients receive one Follow up visit for $50 with your initial price per procedure. You must wait at least 30 days before you can be touched up.
Emerging Public Health Issues: Unnecessary Exposures to Hepatitis-C (Hep-C) Through Sharing of Needles, Illegal Tattooing and Unregulated Body Art (piercings and implants) Hepatitis C (Hep-C): Hep-C is
Welcome to Bella! Give the Gift of Bella. A few tips to prepare you for your first visit: Gift Certificates are just $100 for a $150 value!
Welcome to Bella! We are glad to have you as our guest. We encourage you to visit our website to see all of the exciting new laser and skincare treatments that we offer. Please be aware of our 24 hour
CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR PERMANENT MAKEUP
CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR PERMANENT MAKEUP Name: DOB: Best Phone Contact: Address: Email: List any medications you have been taking in the past 6 months: Have you received chemotherapy
Client Medical History Form
Client Medical History Form Today s Date: Birthday: / / Age Name: TXID# Address: Phone: Email: Tattoo Area: Eye Brows (Micro-Blading) Brand of Ink: Bio Touch Pure / / / Emergency Contact: Phone: Do you
PROPOSAL FORM Tattoo Artists & Body Piercers
Please complete this form in as much detail as possible. Once completed, please submit your proposal form to your Insurance Agent for submission to Underwriters. The completion of this form does not bind
INFECTION PREVENTION AND CONTROL PLAN
INFECTION PREVENTION AND CONTROL PLAN FACILITY NAME: FACILITY ID: ADDRESS: CITY: STATE: ZIP: OWNER S NAME: PHONE: ( ) The owner, employees and practitioners of the above body art facility have developed
STATEMENT OF CONSENT AND RECITALS: Please read and initial all lines. Signed
STATEMENT OF CONSENT AND RECITALS: Please read and initial all lines Aftercare instructions have been explained to me and a written copy will be given to me to retain in my possession, which I will follow
Eyelash Extension History & Consent Form
Eyelash Extension History & Consent Form Client Name: Date: Address: City: State: Zip: Home #: Business #: Cell #: Email: How may we contact you regarding scheduled appointments or specials? Check all
Informed Consent for Light Energy Tattoo Removal
Dr. Joseph G. Protain 813 Kentwood Dr. Boardman, OH 44512 (330)953-3515 Informed Consent for Light Energy Tattoo Removal Customer s name: Date: I, consent to and authorize and members of his/her staff
Hair To Bare South. Client Name: Date:
Hair To Bare South Client Name: Date: I authorize Rachelle Stokes (Hair To Bare South) to perform the treatments. The purpose of these treatments is to diminish or remove unwanted hair. The quantity of
Personal Profile and Health History
--CAPITAL AESTHETICS Personal Profile and Health History Name: Home Phone: Address: Work Phone: City/State/Zip: Date of Birth: Age: Gender: M F Occupation: Email address: How did you hear about us? What
Maya Med Spa 6330 Broadway Blvd. Suite B, Garland, TX Name: Date of birth: Address: Pharmacy of your choice:
Client Consultation Name: Date of birth: Address: Home Phone: Cell Phone: Business Phone: E-mail address: Married: Yes No If yes, anniversary date: Employer: Occupation: Pharmacy of your choice: Does your
Micropigmentation (Semi-Permanent Makeup) Informed Consent
Micropigmentation (Semi-Permanent Makeup) Informed Consent The nature and method of the proposed semi-permanent makeup (cosmetic tattoo) procedure has been explained to me as having the usual risks inherent
Client Questionnaire Skin & Health
Client Questionnaire Skin & Health Please answer the following questions thoroughly and completely, as this provides a better understanding of your general health, lifestyle and skin care concerns; thereby
Date: Date of Birth: Gender: Male Female. City: State: Zip: Caucasion a African-American Hispanic Asian East Indian American Indian
Contact Information: Date: Date of Birth: Gender: Male Female Name: Address: City: State: Zip: Home Phone: Work/Day Phone: Cell: Email: Emergency Contact: Emergency Contact Phone: Medical Background Ethnic
(IF UNDER THE AGE OF 18 YOU MUST BE ACCOMPANIED BY A LEGAL GUARDIAN)
NovaLash Consent Form This form must be read and submitted for NEW NovaLash clients prior to their scheduled appointment. Once guest service has scheduled your first NovaLash appointment, you will be directed
VENUS BEAUTY LOUNGE. Before Your Microblading Session
Great microblading is not a beautiful result directly after treatment. It is a crisp, natural, long-lasting result once healed. Aleksandra Maniuse-Founder Deluxe Brows Microblading is a manual technique
Massey Medical. Medical History (Dermal Filler) MEDICAL INFORMATION: I am interested in the following services: Juvederm: Botox:
Medical History (Dermal Filler) Name: Date: _ Date of Birth: Phone: _ MEDICAL INFORMATION: I am interested in the following services: Juvederm: Botox: NO YES Allergies history of severe allergy or anaphylaxis.
Consent and Release Agreement
Consent and Release Agreement This form is designed to give information needed to make an informed choice of whether or not to undergo a 3D Eyebrow Embroidery Semi-permanent make up application. If you
IPL CONSULTATION AND LIABILITY DOCUMENTATION
Name...... Address:... Date of Birth:... Suburb:... Postcode:... Home Phone:... Mobile:... Email Address:... How did you hear about us?... Contact in case of emergency:... Place a tick in the areas of
APPROVAL REVIEW PROCEDURES
Summit County Public Health 1867 West Market Street Akron, Ohio 44313 Phone: (330) 923-4891 Toll-free: 1 (877) 687-0002 Fax: (330) 923-6436 www.scphoh.org APPROVAL REVIEW PROCEDURES Ohio Law requires that
AREA OF BODY TATTOO IS SITUATED?
CLIENT CONSULTATION LASER TATTOO REMOVAL FORM Address: Date of Birth: Suburb: State: Postcode: Telephone: Work: Mobile Home: Other: Email Address: How did you hear about us? Tattoo Removal Colours in tattoo
Microblading Consent and Release Agreement
Microblading Consent and Release Agreement This form is designed to give information needed to make an informed choice of whether or not to undergo a Microblading semi-permanent make up application. If
Informed Consent For Facial Rejuvenation/Collagen Remodel
Informed Consent For Facial Rejuvenation/Collagen Remodel Client s name: Date: I authorize SilkySkin Laser Centers to perform the laser procedure. You will be treated with the Cynosure Elite TM laser,
ENVIRONMENTAL HEALTH SERVICE REQUEST FORM 2019
Environmental Health Division 1675 W. Garden of the Gods Rd., Suite 2044 Colorado Springs, CO 80907 (719) 578-3199 phone (719) 578-3188 fax www.elpasocountyhealth.org ENVIRONMENTAL HEALTH SERVICE REQUEST
CLIENT HISTORY. May we contact you at these numbers?
CLIENT HISTORY Name: Address: Home Phone: Cell Phone: Email Address: Date of Birth: Street City State Zip Business Phone: May we contact you at these numbers? Other ID: Referred by: Emergency Contact:
SALIBIAN MOSSI. Name Last First Middle. Address Apt. City State Zip. Home Phone Cell Phone Work Phone. Address
Name Last First Middle Address Apt. City State Zip Home Phone Cell Phone Work Phone Email Address Age Date of Birth Sex Height Weight Marital Status Drivers License # Social Security # Employer Occupation
GENERAL ASSEMBLY OF NORTH CAROLINA SESSION 2001 H 1 HOUSE BILL 635. March 15, 2001
GENERAL ASSEMBLY OF NORTH CAROLINA SESSION 00 H HOUSE BILL Short Title: Regulate Body Piercing. Sponsors: Representatives Mitchell; Capps and Setzer. Referred to: Finance. (Public) March, 00 0 A BILL TO
Client Medical History Form
Client Medical History Form Date Birth Date Age DL or ID# Name: Address City State Zip Phone Email Emergency contact person Phone Do you presently have or previously had any of the following: (Circle yes
THE GENERAL ASSEMBLY OF PENNSYLVANIA HOUSE BILL
PRIOR PRINTER'S NOS., PRINTER'S NO. THE GENERAL ASSEMBLY OF PENNSYLVANIA HOUSE BILL No. Session of 0 INTRODUCED BY R. BROWN, BOBACK, CALTAGIRONE, COHEN, DAY, DEASY, DONATUCCI, FRANKEL, HARKINS, HEFFLEY,
Microblading Consent Form Client Medical History: Date Birthdate Age Name Form of Id # Address
Microblading Consent Form Client Medical History: Date Birthdate Age Name Form of Id # Address Phone Email Emergency Contact Person Phone Do you have or previously had any of the following: (Circle YES
Address City State ( ) 32 YES NO. 33 YES NO Are you undergoing radiation or chemo-therapy treatment? 39 YES NO 45 YES NO
CLIENT HISTORY FORM Print Name Location of Service: Email @ Birth Date Age Gender Female Address City State / Male Emergency Contact Name Home Phone ( ) Cell Phone ( ) Today s Procedure Description: Eyebrows
BODY ART FACILITY PLAN REVIEW OVERVIEW
BODY ART FACILITY PLAN REVIEW OVERVIEW The City of Pasadena Public Health Department, Environmental Health Division shall issue a health permit for a body art facility after an investigation has determined
BODY ART ESTABLISHMENT PLANNING APPLICATION
BODY ART ESTABLISHMENT PLANNING APPLICATION Toledo-Lucas County Health Department 635 N. Erie Street Toledo-Lucas Toledo, County OH Health 43604 Phone: (419) 213-4100 Department ext. 3 Fax: (419) 213-4141
A Bill Regular Session, 2007 SENATE BILL 276
Stricken language would be deleted from and underlined language would be added to the law as it existed prior to this session of the General Assembly. Act 0 of the Regular Session State of Arkansas th
As Engrossed: S2/1/01. By: Representatives Bledsoe, Borhauer, Bond, Rodgers, Green. For An Act To Be Entitled
Stricken language would be deleted from and underlined language would be added to the law as it existed prior to this session of the General Assembly. 0 State of Arkansas As Engrossed: S//0 rd General
GENERAL CONSENT FORM
GENERAL CONSENT FORM Please read this form fully, initial each line item and sign at the end. If you are unsure about a detail of the form, please speak to your practitioner. If unforeseen conditions arise
CLEAR TOE INTAKE INFORMATION
CLEAR TOE INTAKE INFORMATION Name: Today s Date: Last First MI Street address: City: State: Zip: Date of birth: Age: Sex: Female Male Home Phone: Cell Phone: Leave messages at: Home Cell Other: Email address:
Consultation Form: Coffeeberry Peel
Consultation Form: Coffeeberry Peel NAME: ADDRESS: TELEPHONE NUMBER: DATE OF BIRTH: EMERGENCY CONTACT: EMAIL ADDRESS: OCCUPATION: DOCTORS NAME/SURGERY: We aim to ensure clients have the best possible advice
Client Medical History Form
Client Medical History Form Date Birthdate Name Address Phone Email Emergency Contact Person Phone Do you have or previously had any of the following: (Circle YES or NO) YES NO History of MRSA YES NO Botox
Body Art Facility Infection Prevention And Control Plan Guideline
Body Art Facility Infection Prevention And Control Plan Guideline In accordance with the California Health and Safety Code, Section 119313, a body art facility shall maintain and follow a written Infection
BODY ART /PIERCING PLAN REVIEW APPLICATION AND GUIDELINES
BODY ART /PIERCING PLAN REVIEW APPLICATION AND GUIDELINES Plan Review Request for a Body Art/Piercing Establishment Instructions 1. Complete the form and attached requested information in plan review packet.
Welcome to Medspa 1064, Connecticut s Premier Center for Cosmetic Laser Medicine
MedSpa 1064 Suites at Somerset Square 140 Glastonbury Blvd. Glastonbury, CT 06033 860.657.1064 Welcome to Medspa 1064, Connecticut s Premier Center for Cosmetic Laser Medicine This form is to introduce
BODY ART TEMPORARY EVENT SPONSOR APPLICATION PACKET
BODY ART TEMPORARY EVENT SPONSOR APPLICATION PACKET Attached are instructions for event sponsors and body artist participants. The information should be read carefully. The sponsor must work with the Kern
Client Intake Form. Name: Date: Address: City: ST: Zip: Phone:
Client Intake Form Name: Date: Last First Address: City: ST: Zip: Email: Phone: How did you hear about Skin Renew Day Spa? What are your main concerns? How long have you been experiencing your current
Gangs, Tattooing, and Piercing
Gangs, Tattooing, and Piercing What You NEED to Know A guide for refugee and immigrant youth and their families regarding the risks of certain behaviors in American culture. Alana Schriver, Omaha Public
CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR MICROBLADING
CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR MICROBLADING Name: DOB: Best Phone Contact: Address: Email: List any medications you have been taking in the past 6 months: Age Have you received chemotherapy
City State Zip. Model Dress size 6X 10 Height Weight Date of Measurement
Model Application 2016 American Girl Fashion Show Presented by the Junior League of the Lehigh Valley Saturday, March 5, 2016 10 AM & 2 PM Sunday, March 6, 2016 10 AM & 2 PM Model Fee $40 Thank you for
BODY ART FACILITY INFECTION PREVENTION AND CONTROL PLAN
BODY ART FACILITY INFECTION PREVENTION AND CONTROL PLAN In accordance with the California Health and Safety Code, Section 119313, a body art facility shall maintain and follow a written Infection Prevention
INFORMED CHEMICAL PEEL CONSENT. 1. I authorize the chemical peel listed above, to my face and / or neck, chest and hands.
INFORMED CHEMICAL PEEL CONSENT 1. I authorize the chemical peel listed above, to my face and / or neck, chest and hands. 2. Depending on the chemical peel site, there may be redness and/or irritation and
How did you hear of us? Friend: Our patient: Magazine: Physician referral:
Patient Information Today s Date: Title: Dr. Mr. Mrs. Ms. Name (Last, First, Middle) Gender: M F Age: Birthdate: Social Security: Street Address City, State & ZIP Home Phone Cell Phone Work Phone Email
BODY ART FACILITY INFECTION PREVENTION AND CONTROL PLAN GUIDELINE
Ventura County Environmental Health Division 800 S. Victoria Ave., Ventura CA 93009-1730 TELEPHONE: 805/654-5007 FAX: 805/477-1595 Internet Web Site Address: https://vcrma.org/body-art-program BODY ART
CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR MICROBLADING
CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR MICROBLADING Name: DOB: Phone : Address: Email: List any medications you have been taking in the past 6 months: Have you received chemotherapy or radiation
Registration & History Form. Client Name: Date: Address: City: State: Zip: Phone No.: Birthday: Anniversary: How did you hear about us?
Registration & History Form Client Name: Date: Address: City: State: Zip: Phone No.: Email: Birthday: Anniversary: How did you hear about us? Name of person who referred you: Phone: Question Y N Date and
CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR MICROBLADING
CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR MICROBLADING Name: DOB: Best Phone Contact: Address: Email: List any medications you have been taking in the past 6 months: Have you received chemotherapy
Remove bandage after two hours petroleum free For the first 3-5 days After a few days When you discontinue the plastic wrap petroleum free
TATTOO HEALING CARE Once the tattoo procedure is done, proper aftercare is essential to the healing, and will affect the outcome of your tattoo. Improper care or neglect during the healing process can
INFECTION PREVENTION AND CONTROL PLAN (IPCP)
INFECTION PREVENTION AND CONTROL PLAN (IPCP) FACILITY NAME: FACILITY ID: ADDRESS: CITY: STATE: ZIP: OWNER S NAME: PHONE: CONTACT PERSON: EMAIL: The owner, employees and practitioners of the above body
TIME-LIMITED BODY ART/PIERCING APPLICATION AND GUIDELINES
TIME-LIMITED BODY ART/PIERCING APPLICATION AND GUIDELINES Time-Limited Body Art/Piercing Application and Guidelines Licensing Process 1. Read this entire packet. 2. Complete the License Application form.
TATTOO & BODY PIERCING INSURANCE APPLICATION
TATTOO & BODY PIERCING INSURANCE APPLICATION National A Rated Company Preferred Rate Plan 24/7 Claims Service Payment Plans Available Producer: APPLICANT INFORMATION (Required) APPLICANT S NAME (include
(Injection of collagen, hyaluronic acid or other filler materials) INFORMED CONSENT FOR DERMAL FILLER
INFORMED CONSENT FOR DERMAL FILLER (Injection of collagen, hyaluronic acid or other filler materials) INTRODUCTION Dermal fillers are injected just under the skin s surface in order to temporarily correct
Plan Review Application for Tattooing or Piercing
Plan Review Application for Tattooing or Piercing If you have questions or need further assistance please contact us. Please mail, email or deliver application to: RiverStone Health - Environmental Health
CHAPTER 114: TATTOO AND BODY PIERCING SERVICES
CHAPTER 114: TATTOO AND BODY PIERCING SERVICES Section 114.01 Definitions 114.02 Prohibitions 114.03 Application for license; fees; issuance 114.04 Inspection of facilities 114.05 Suspension or revocation
Forename Surname... SOPRANO ICE SHR LASER CONSULTATION FORM
Forename Surname... SOPRANO ICE SHR LASER CONSULTATION FORM 1 SOPRANO ICE SHR PERSONAL INFORMATION Gender: Male/Female Date of birth.age. Home address..postcode.. Telephone..Mobile.. Email address.. GP
2017 American Indian Arts Marketplace at the Autry November 11 & 12, 2017
2017 American Indian Arts Marketplace at the Autry November 11 & 12, 2017 Artist Booth Application Applications must be received by Friday, May 26, 2017 Application fee of $25. (non-refundable) is due
Microblading. More information can be found at the Society of Permanent Cosmetic Professionals.
Microblading (eyebrow tattooing, eyebrow embroidery, microstroking, micropigmentation, dermal implantation, permanent cosmetics, feathering eyebrows cosmetic tattooing) Any time color is placed into the
Client Information Sheet
Esthetic Laser Clinic 8381 Old Courthouse Road Suite 300 Vienna, VA 22182 (703) 288 0085 www.elaserclinic.com Client Information Sheet Last Name First Name: Address City State Zip Code D.O.B. (MM/DD/YY)
CHAPTER Committee Substitute for House Bill No. 729
CHAPTER 2010-220 Committee Substitute for House Bill No. 729 An act relating to the practice of tattooing; creating s. 381.00771, F.S.; defining terms; creating s. 381.00773, F.S.; exempting certain personnel
GENERAL CONSENT AND PROCEDURE PERMIT FORM
GENERAL CONSENT AND PROCEDURE PERMIT FORM Please read this form fully and sign at the end. If you are unsure about a particular detail of the form, please speak to your therapist. If unforeseen condition
HEALTH HISTORY. Name Date DOB Age. Home Phone Work Mobile Other
HEALTH HISTORY To ensure both the effectiveness and the safety of your treatment, please complete this health history as accurately as you can. PERSONAL INFORMATION Name _ Date DOB Age Address _ City State
PRODUCT YES / NO BRAND NAME PRODUCT NAME FREQUENCY OF USE
Consultation Form Today s Date: Name: Your Birthday: Spouses Name: Spouses Birthday: Anniversary: Address: City: St: Zip Home Phone: Office Phone: Cell Phone: Email Address: Purpose for visit: How did
TATTOOIST AND BODY PIERCING
TATTOOIST AND BODY PIERCING INSTRUCTIONS TO APPLICANTS A. LICENSE BY EXPERIENCE: Applicants must submit the following: 1. Complete Application 2. Application Fee of $75.00 (n-refundable Processing Fee)
Aesthetic Patient Form
Aesthetic Patient Form Name: Date: Address: City: State: Zip: Home Phone: Work Phone: Cell: Age: Date of Birth: Occupation: Email: FITZPATRICK CLASSIFICATION SYSTEM: Please select the skin type that seems
Intake Form Chemical Peels, Microdermabrasion, and Facials
Intake Form Chemical Peels, Microdermabrasion, and Facials Name: Today s Date: Last First MI Street address: City: State: Zip: Date of birth: Age: Sex: 0 Female 0 Male Home Phone: Cell Phone: Leave messages
PUBLIC HEALTH DEPARTMENT
ROBIN HODGKIN, M.P.A. Director STEPHEN W. MUNDAY, M.D., M.S. Health Officer COUNTY OF IMPERIAL PUBLIC HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH 797 Main Street, Ste. B El Centro, CA 92243 Phone
LOCAL LAW NO. 4 FOR 1999 A LOCAL LAW OF THE COUNTY OF ALBANY, NEW YORK REGULATING TATTOOING AND BODY PIERCING
LOCAL LAW NO. 4 FOR 1999 A LOCAL LAW OF THE COUNTY OF ALBANY, NEW YORK REGULATING TATTOOING AND BODY PIERCING Introduced: 7/12/99 By Mr. Domalewicz: BE IT ENACTED by the Legislature of the County of Albany
BODY ART GUIDELINES. Purpose. Definitions. Body Art Technician Requirements
BODY ART GUIDELINES Purpose This guideline provides general explanations of procedures for the maintenance and operation of body art facilities and permitting requirements for body art technicians. Please
CHAPTER 18 LICENSURE AND REGULATION OF BODY PIERCING AND TATTOOING
CHAPTER 18 LICENSURE AND REGULATION OF BODY PIERCING AND TATTOOING 18.01 AUTHORITY AND PURPOSE 18.02 APPLICABILITY 18.03 DEFINITIONS 18.04 LICENSES 18.05 LIMITATIONS 18.06 RECORDS 18.07 HEALTH AND SANITARY
NEW PATIENT FORM. Full Name: Date of Birth Age : (First) (Middle) (Last) Address: (Street) (City) (State) (Zip code) Home #: ( ) Work Number : ( )
Office Use Only: Booker Mailchimp Referral Driver s License NEW PATIENT FORM Today s Date: Reason(s) for Today s Visit: Full Name: Date of Birth Age : (First) (Middle) (Last) Address: (Street) (City) (State)
It is unlawful to operate a tattoo shop or establishment without first obtaining a license as required by this chapter.
5.70.010 - License required. 5.70.020 - Requirements for building or operator. 5.70.030 - Tattooing procedure regulations. 5.70.040 - Health-related requirements. 5.70.050 - Recordkeeping. 5.70.060 - Unlawful
ibrow Studio Client Information Packet
ibrow Studio Client Information Packet Thank you so much for trusting me with your beautiful face! Prior to booking an appointment, we ask that all ibrow Studio clients read and review the information
Would you like to receive informational updates, specials and newsletters? Yes No
Patient Contact Information Name Home Phone Work Phone Cell Phone Home Address City State Zip E-Mail Date of Birth Emergency Contact Name and Phone Who Referred You To This Clinic? Would you like to receive
What you need to know about body art, from piercings to tattoos
Non-fiction: Making Your Mark Making Your Mark By Mark Rowh What you need to know about body art, from piercings to tattoos When Savanna P. looks in the mirror, she sees herself as a work of body art.
5504 Backlick Road Springfield, Virginia
Name: Address: Phone: City: Zip Code: Cell: Phone: Text Cell Phone email How did you hear about us: General Health State: Contact me by 1. Rate your level of stress: (5 = highest, 1= lowest) 5 4 3 2 1
Which trimester? 1 2 3
Registration & History Form Client Name: Date: Address: City: State: Zip: Home #: Business #: Cell #: Fax #: Email: Facebook Account: Twitter Name: How may we contact you regarding scheduled appointments
Informed Consent for Dermal Filler
Informed Consent for Dermal Filler NAME: DATE OF BIRTHG: ADDRESS: CELL PHONE: EMAIL: www.medicaleyecenter.com Please initial all of the following sections confirming that you have read and understand each
City and County of Denver Rules and Regulations for Body Artist, Body Art Establishments, and Mobile Body Art Vehicles Chapter 24 DRMC
City and County of Denver Rules and Regulations for Body Artist Body Art Establishments and Mobile Body Art Vehicles Chapter 24 DRMC Adopted by the Board of Environmental Health on March 11 1999 And Amended
HEALTH HISTORY INFORMATION
HEALTH HISTORY INFORMATION Name: Today s Date: Last First MI Street address: City: State: Zip: Date of birth: Age: Sex: Female Male Home Phone: Cell Phone: Leave messages at: Home Cell Other: Email address:
Patient Contact Information. Name. Home Address. City State Zip
Patient Contact Information Name Home Phone Work Phone Cell Phone Home Address City State Zip E-Mail Date of Birth Emergency Contact Name and Phone Who Referred You To This Clinic? Would you like to receive