Fillable Patron Consent Form printable pdf download

Aspen Spa and Salon

The Shops at Boardwalk

STATE OF MISSOURI

8636 N. Boardwalk

DIVISION OF PROFESSIONAL REGISTRATION

Kansas City, MO 64154

PATRON CONSENT

SECTION I. PATRON’S INFORMATION

PATRON’S NAME (FIRST, MIDDLE, LAST) If patron is under the age of eighteen (18) parent or legal guardian’s name shall also be provided.

PATRON’S DATE OF BIRTH

PATRON’S ADDRESS (STREET, CITY, STATE, ZIP CODE)

PATRON’S RESIDENCE PHONE NUMBER

PATRON’S DRIVER LICENSE NUMBER/IF UNDER AGE OF EIGHTEEN, DRIVER’S LICENSE NUMBER OF PARENT OR LEGAL GUARDIAN.

PATRON’S DRIVER LICENSE NUMBER

PARENT OR LEGAL GUARDIAN’S DRIVER LICENSE NUMBER

PROCEDURE(S) TO BE PERFORMED (CHECK ALL THAT APPLY)

TATTOO

BODY PIERCING (PART OF BODY TO BE PIERCED ____________________)

BRAND

SECTION II. MEDICAL/HEALTH ASSESSMENT – QUESTIONS ARE TO BE ANSWERED BY THE PATRON.

YES

Are you currently or have you ever used medications that contain a controlled substance?

Have you ever been diagnosed by a medical doctor as to having contracted communicable disease such as Human

Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and/or other blood borne pathogens? If so, when?

Have you ever been diagnosed by a medical doctor as having allergies?

Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process,

including diabetes?

Are you currently under the influence of any illegal substances?

Are you currently under the influence of an alcoholic beverage?

Have you been diagnosed with jaundice within the past twelve months?

Are you currently using any medications that contain blood thinners?

Are you currently using any medications that weaken the immune system that fights infections?

SECTION III. TO BE COMPLETED BY PATRON

I, ___________________________________________ , acknowledge that I am aware certain medical conditions and treatments and/or

medications used to treat those medical conditions may be adversely impacted by the procedure(s) of tattooing and/or body piercing and/or

branding. Such medical conditions include but are not limited to, impaired kidney and/or liver function, diabetes, jaundice, medication

con-

taining blood thinners and medications that weaken the immune system.

I further acknowledge that the tattoo and/or brand should be considered permanent; that said tattoo and/or brand can only be removed with

a surgical procedure; and that any effective removal may leave permanent scarring and disfigurement.

I have read this form and confirm that all the information I have given is correct. I understand that this is a consent form and I agree to be

legally bound by it.

SIGNATURE OF PATRON

DATE

SIGNATURE OF PARENT/LEGAL GUARDIAN (IF PATRON IS UNDER THE AGE OF EIGHTEEN)

DATE

SECTION IV. TO BE COMPLETED BY PRACTITIONER

I, ___________________________________________ , have reviewed this consent form and have advised the above named patron both

in writing and verbally of the dangers and contradictions of the procedure that is to be performed.

SIGNATURE OF PRACTITIONER

LICENSE NUMBER

DATE

MO 375-0200 (9-06)

Patron Consent Form

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