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
Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19
The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people
Lucky’s Tattoo and Piercing have put in place preventative measures to reduce the spread of COVID-19; however, Lucky’s Tattoo and Piercing cannot guarantee that you will not become infected with COVID-19. Further, getting a tattoo or piercing could increase your risk of contracting COVID-19.
By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by entering Lucky’s Tattoo and Piercing and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Lucky’s Tattoo and Piercing employees.
I voluntarily agree to assume all of the possible risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury. disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my attendance at Lucky’s Tattoo and Piercing.
I hereby release, discharge, and hold harmless Lucky’s Tattoo and Piercing LLC, its employees, agents, of and from the Claims, including all liabilities, claims, actions, damages, costs, or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of Lucky’s Tattoo and Piercing employees, agents, whether a COVID-19 infection occurs before, during, or after participation in any tattoo, piercing work, or any other services provided by Lucky’s Tattoo and Piercing LLC.
CLIENT HEALTH QUESTIONNAIRE
PRIOR TO THE START OF MY SERVICE, I CONFIRM THAT:
I have not been diagnosed with or cared for someone diagnosed with COVID-19 in the past two weeks.
I have not shown symptoms of COVID-19 or come in close contact with anyone exhibiting these symptoms in the past two weeks.
I have not traveled outside of my immediate daily routine for the past two weeks.
I do not have a cough, fever, chills, shortness of breath, or loss of taste or smell.
If I begin to show symptoms of COVID-19 within the next two weeks, I will contact Lucky's Tattoo and Piercing as soon as possible.
I will follow all posted studio rules to keep myself, studio staff, and those around me safe.
ALL TATTOO CLIENTS MUST SIGN AND RECEIVE A COPY OF THIS FORM, PRIOR TO ANY TATTOO PROCEDURE. KEEP ORIGINAL FORM ON PREMISES.
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 .
The following conditions may increase health risks associated with receiving a tattoo:
(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 prevewnts me from receiving a tattoo
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 piercing
(c) unexpected drainage at or from the site of the piercing
(d) fever within 24 hours of the piercing
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: September 28, 2022