An example of an Informed Consent/Medical Questionnaire/Aftercare Form can be found here.
An Informed Consent Form must be completed by the client prior to the performance of body art.
The client shall read, complete, and sign an informed consent form that shall include, but not be limited to, all of the following information:
- A description of the procedure.
- A description of what the client should expect following the procedure, including suggested care and any medical complications that may occur as a result of the procedure.
- A statement regarding the permanent nature of body art.
- A notice that tattoo inks, dyes, and pigments have not been approved by the federal Foodand Drug Administration and that the health consequences of using these products areunknown.
- Post procedure instructions that include all of the following:
- Information on the care of the procedure site.
- Restrictions on physical activities such as bathing, recreational water activities,gardening, or contact with animals, and the duration of the restrictions.
- Signs and symptoms of infection, including, but not limited to, redness, swelling,tenderness of the procedure site, red streaks going from the procedure site towardsthe heart, elevated body temperature, or purulent drainage from the procedure site.
- Signs and symptoms that indicate the need to seek medical care.
A Medical Questionnaire must be completed by the client prior to the performance of body art.
The client shall receive, complete, and sign a questionnaire that includes all of the following information:
- Whether the client may be pregnant.
- Whether the client has a history of herpes infection at the proposed procedure site, diabetes, allergic reactions to latex or antibiotics, hemophilia or other bleeding disorder, or cardiac valve disease.
- Whether the client has a history of medication use or is currently using medication, including being prescribed antibiotics prior to dental or surgical procedures.
- Other risk factors for blood-borne pathogen exposure.
All information gathered from the client that is personal medical information and that is subject to the federal Health Insurance Portability and Accountability Act of 1996 (HIPPA) or similar state laws shall be maintained or disposed of in compliance with those provisions.
Aftercare instructions must be provided to the client.