Central Ink Tattoo and Body Piercing

#80 Central Mall, Lawton Ok 73505 Shop Phone 15806998828 or 15806998829

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Please Circle One Date of Birth City CELL

Body Piercing
Name Address Phone

Tattoo
Todays Date State Zip Code

Please answer the following Are you under the influence of drugs? Have you been Drinking in the last 8 Hours? Have you eaten in the last 6 Hours? Name Diabetes Aids/Hiv Tuberculosis Mental Illness Circle One Yes No Yes No Yes No Yes No

Circle One Yes No Yes No Yes No

Time ________________________________ Time ________________________________ Time ________________________________ Circle One Yes No Yes No Yes No Yes No Name Anemia Nursing Seizures Epilepsy Circle One Yes No Yes No Yes No Yes No
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In order for proper healing of your body art procedure, we ask that you disclose the followingHave you ever been diagnosed with any of the following? Or are You Currently.

Name Syphilis Hepatitis Hepatitis B Narcolepsy

Circle One Name Yes No Gonorrhea Yes No Encephalitis Yes No Hemophilia Yes No Pregnancy Please List if any of these currently apply

Are you on any kind of medications? Do you suffer from any condition that may cause abnormal healing? Have you had any serious or chronic illness, operations, chronic viral infections, or traumatic accidents? Do you suffer from skin lesions, sensitivity to soaps, disinfectants or have allergies, or other skin sensitivities? In case of Emergency please notify:
Name Phone
Disclosure statement for tattooing and body piercing Clients of Tattoo and Body Piercing establishments should be aware that although the establishment complies with all rules of sanitation and sterilization, it is still possible that a blood borne disease or infection could be contracted as a result of a Tattoo or Body Piercing procedure.I, the undersigned, have read and understood the above foregoing Disclosure Statement and acknowledge the possible effects/Consequences.

Client Printed Name/ Client Signature

Parent or Guardian If Under 18 for Body Piercing ONLY Description of Procedure: Jewelry & Piercing

Artist Signature/ Artist License # Notice for Filing a Complaint Any person with personal knowledge about a violation of the Body Piercing and Tattooing Rules may file a complaint in writing to the Oklahoma State Department of Health, Consumer Protection Division 1000 NW 10th Street, Oklahoma City, OK 73117-1299

At The First Sign Of Infection Please Contact A Physician