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Cambridge Tattoo Disclosure

Don't forget to bring government issued photo ID with you to your appointment, its required!

 

Cambridge Public Health Department 

Company Contact Information

Company Name: Lucky's Tattoo and Piercing

Address: 694 Massachusetts Avenue, Cambridge, MA 02139

Phone: 617-945-0317  

 

TATTOO DISCLOSURE STATEMENT AND CONSENT FORM

  • As with any invasive procedure, tattooing may involve possible health risks. These risks may include:
  • (a) pain, bleeding, swelling;
  • (b) scarring, hypertrophic scarring, and keloid formation;
  • (c) possible adverse or allergic reaction to ink / dye I pigment;
  • (d) decreased ability of physician to locate skin melanoma in tattoo area;
  • (e) possible nerve damage;
  • (f) febrile (fever) illness;
  • (g) tetanus; and
  • (h) infection - local or systemic
  • Unsterile equipment and needles can spread infectious diseases; it is extremely important to be sure that all equipment is clean and sanitary before use.
  • The inks, or dyes, used for tattoos are color additives. Currently no color additives have been approved by the FDA for tattoos.
  • Tattoos and micropigmentation / microblading should be considered permanent. Removal of a tattoo may require surgery or other medical procedures which in some cases may result in scarring or additional scarring of the skin. Tattoos may cause permanent discoloration. Inks / dyes / pigments may change color over time. Think carefully before getting a tattoo.
  • Blood donations cannot be made for one year after getting a tattoo. 

The Tattoo Practitioner should:

  • Properly and thoroughly cleanse the area before the tattooing procedure.
  • Use sterilized equipment.
  • Use sterile techniques.
  • Provide information on the aftercare of the area receiving a tattoo, aftercare available at http://www.luckystattoo.org/tattoo-aftercare-instructions . 

HEALTH HISTORY

The following conditions may increase health risks associated with receiving a tattoo: 

(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 blood and/or interfere with blood clotting; and

(g) hepatitis or HIV infection 

I have read and understand the above information


I do not have a condition that prevents me from receiving a tattoo


I am not under the influence of any drug or alcohol 


I am not pregnant and don't suspect that I may be pregnant


I consent to the performance of the tattooing procedure and I have been given verbal and written aftercare instructions as required by the Cambridge Body Art Regulation


I am aware that all information disclosed will be kept confidential 


I am aware that a copy of this document will be provided to me


Consult a health care provider for:

(a) unexpected redness, tenderness or swelling at the site of the tattoo

(b) rash

(c) unexpected drainage at or from the site of the tattoo

(d) fever within 24 hours of the tattoo 

PROCEDURE FOR FILING A COMPLAINT

If there is any sign of injury, infection, complication or disease as a result of a tattoo procedure, first contact a healthcare provider for medical evaluation. Then notify this establishment and the CAMBRIDGE PUBLIC HEALTH DEPARTMENT, 119 WINDSOR STREET, CAMBRIDGE, MA 02139. Phone: (617) 665-3848. 

Today's Date: October 30, 2024

 


First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
I understand that the artist is a licensed*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
I understand that the artist is a licensed*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
I understand that the artist is a licensed*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
I understand that the artist is a licensed*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
I understand that the artist is a licensed*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
I understand that the artist is a licensed*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
I understand that the artist is a licensed*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
I understand that the artist is a licensed*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
I understand that the artist is a licensed*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
I understand that the artist is a licensed*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
I understand that the artist is a licensed*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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