BODY PIERCING DISCLOSURE STATEMENT

THIS STATEMENT IS TO BE GIVEN TO ALL BODY ART CLIENTS, AND IS TO BE SIGNED BY THE CLIENT, PRIOR TO PERFORMING ANY BODY ART PROCEDURE

As with any invasive procedure, body piercing may involve possible health risks.
These risks may include:
•	Pain, bleeding, swelling, infection, scarring of the area and nerve damage.
•	Unsterile equipment and needles can spread infectious diseases; it is extremely important to be sure that all equipment is clean and sanitary before use.
•	You may not be allowed to donate blood either temporarily or permanently. 

The Body Art Practitioner should 
•	Properly and thoroughly cleanse the area before the procedure
•	Use sterilized equipment
•	Use sterile techniques
•	Provide information on the aftercare of
•	the area receiving body art 

TATTOO DISCLOSURE STATEMENT
•	As with any invasive procedure, tattooing may involve possible health risks.  These risks may include:
•	Pain, bleeding, swelling, infection, scarring of the area and nerve damage 
•	Unsterile equipment and needles can spread infectious diseases; it is extremely important to be sure that all equipment is clean and sanitary before use
•	Tattoos and permanent makeup are not easily removed and in some cases may cause permanent discoloration; think carefully before getting a tattoo.  The is also the possibility of an allergic reaction.
•	The inks, or dyes, used for tattoos are color additives.  Currently no color additives have been approved by FDA for tattoos, including those used in permanent makeup
•	Blood donations cannot be made for a year after getting a tattoo or permanent makeup

The Body Art Practitioner should
•	Properly and thoroughly cleanse the area before the procedure
•	Use sterilized equipment
•	Use sterile techniques
•	Provide information on the aftercare of the area receiving body art

HEALTH HISTORY AND INFORMED CONSENT
The following conditions may increase health risks associated with receiving body art:
(a)	diabetes;
(b)	hemophilia (bleeding);
(c)	skin diseases, lesions, or skin sensitivities to soaps, disinfectants etc.;
(d)	history of allergies or adverse reactions to pigments, dyes, or other sensitivities;
(e)	history of epilepsy, seizures, fainting, or narcolepsy;
(f)	use of medications such as anticoagulants, (such as coumadin) which thin the bloodand/or interfere with blood clotting; and
(g)	hepatitis or HIV infection

INSTRUCTIONS FOR THE AFTERCARE OF TATTOOS
Treat your new tattoo as an open wound.  Keep it clean. Do not touch healing tattoos with dirty hands.
•	Before cleaning the tattooed area, wash hands thoroughly with soap and warm water.
•	Carefully remove the gauze bandage and tape. If the gauze sticks, use a tiny bit of warm water to remove. DON'T RIP IT OFF!
•	Using mild soap and cool water, gently and carefully cleanse the area, and pat dry. Do not rub with washcloth or towel 
•	Apply a thin layer of antibiotic ointment (Bacitracin, Neomycin-Polymyxin) on the
•	tattoo.
•	Repeat cleansing and application of the antibiotic ointment 2-4 times a day for 3
•	days.
•	Healing usually takes 7 to 10 days, depending on the size of the tattoo.  As it
•	heals, expect peeling like sunburned skin. 
•	Do not pick at scabs
•	Avoid sunburn, salt or chlorinated pool water, hot tubs, saunas and steam baths while the tattoo is healing 
•	Itching is expected. DO NOT SCRATCH THE TATTOO!

Consult a health care provider for:
1.	unexpected redness, tenderness or swelling at the site of the tattoo
2.	rash
3.	unexpected drainage at or from the site of the tattoo
4.	fever within 24 hours of the tattoo 

INSTRUCTIONS FOR THE AFTERCARE OF PIERCINGS
Treat your new piercing as an open wound.  Keep it clean. Body piercings need to be cleaned once or twice daily, every day, for the entire initial healing time. Do not touch healing piercings with dirty hands.
•	Before cleanings, wash hands thoroughly with soap and warm water.
•	Rinse or soak the pierced area with warm water to remove any stubborn crust using a cotton swab and warm water.
•	Apply a small handful of mild antibacterial soap to the area with your clean hands.
•	Cleanse the area and the jewelry, and gently rotate the jewelry back and forth a few times to work the soap to the inside.
•	Allow the solution to remain there for a minute. Bathe normally; don't purposely work anything other than the cleanser onto the inside of the piercing.
•	Rinse the area thoroughly under running water, while rotating the jewelry back and
•	forth to completely remove the cleanser from the inside and outside of the
•	piercing.
•	Gently pat dry with disposable paper products such as gauze or tissues, as
•	cloth towels can harbor bacteria. 
•	
Consult a health care provider for:
1.	unexpected redness, tenderness or swelling at the site of the piercing
2.	rash
3.	unexpected drainage at or from the site of the piercing
4.	fever within 24 hours of the piercing

PROCEDURE FOR FILING A COMPLAINT
If there is any injury, infection complication or disease as a result of a body art procedure notify this establishment, and the following local board of health at (Name, address and telephone number of Board of Health): __________________________________________________________________________________________________________________________________________________________________________

CLIENT SIGNATURE
I have received the above information.  I do not have a condition that prevents me from receiving body art. I consent to the performance of the body art procedure and I have been given verbal and written aftercare instructions as required by these regulations.
Signature*                                     Date:                                  
*Parent or guardian signature required if under the age of 18.  Relationship: ___________