Cody Reed Client Body Art Record and Consent Form

License # BA-02302

Minor Clients

If the client is a minor, the following must be included in the file:

• Proof of parental or legal guardian identification in the form of a photo identification. Acceptable forms of ID include a driver’s  license, a passport, or state or government-issued identification that includes the parent’s or legal guardian’s name, picture and  date of birth.

• A copy of the minor’s birth certificate and/or court document verifying the parent’s or legal guardian’s relationship with the  minor.

Note: The minor’s parent or legal guardian must execute the written informed consent in the presence of the body art technician  performing the body art procedure or another individual working in the body art facility.

Client Health Questionnaire

Before starting a body art procedure, each person seeking a tattoo, branding or body piercing shall be asked about the following conditions:

• History of hemophilia or excessive bleeding

• Diabetes or other conditions which may affect blood circulation and/or ability to fight infection.

• History of skin disease, skin lesions, or skin sensitivities to soaps or disinfectants

• History of allergies or adverse reactions to latex, pigments, dyes, disinfectants, metals or other sensitivities related to body art  procedures

• History of epilepsy, seizures, fainting or narcolepsy

• Treatment with anticoagulants or other medications that thin the blood and/or interfere with blood clotting

• Current pregnancy and/or breast-feeding

• Any other information that would aid the body art technician or any other individual involved in providing education on the  client’s suitability for receiving a body art procedure and the client’s body healing process

Any client reporting one or more of the above conditions should be encouraged to consult their physician before undergoing a body art  procedure.

ADDITIONAL PERMANENT COSMETICS/TATTOO CONSENT

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. 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 that  I am over eighteen (18) years of age.

• I acknowledge it is not reasonably possible for the associates, agents and representatives of The Studio 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 The Studio that are reasonable  necessary to perform the tattoo procedure.

• I agree to release and forever discharge and forever hold harmless The Studio 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..

• 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.

Client Consent

I acknowledge that I have received a copy of the Disclosure Statement and Notice for Filing Complaints, received a copy of the  Aftercare Information Sheet, and completed the Client Health Questionnaire and received any additional, applicable information.

In addition, this record serves as signed documentation that the body art facility performing your tattoo, piercing, and/or branding is a  licensed facility by the State of Michigan. It is recommended that individuals or organizations visit www.michigan.gov/bodyart  to  determine current the license status of the body art facility before proceeding with any body art procedure.