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Cambridge Piercing 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  


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 Agree

I have not shown symptoms of COVID-19 or come in close contact with anyone exhibiting these symptoms in the past two weeks. 

I Agree

I do not have a cough, fever, chills, shortness of breath, or loss of taste or smell. 

I Agree

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 Agree

I will follow all posted studio rules to keep myself, studio staff, and those around me safe. 

I Agree

 

 

 

ALL BODY ART CLIENTS MUST SIGN AND RECEIVE A COPY OF THIS FORM, PRIOR TO ANY TATTOO PROCEDURE. KEEP ORIGINAL FORM ON PREMISES.

BODY PIERCING DISCLOSURE STATEMENT AND CONSENT FORM

  • As with any invasive procedure, tattooing may involve possible health risks. These risks may include:
  • (a) pain
  • (b) bleeding
  • (c) swelling
  • (d) infection
  • (e) scarring of the area; and
  • (f) nerve damange
  • Unsterile equipment and needles can spread infectious diseases; it is extremely important to be sure that all equipment is clean and sanitary before use.
  • You may not be allowed to donate blood either temporarily or permanently

The Piercing Practitioner should:

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

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 

(Not our recommended aftercare. We will give you written aftercare)

RECOMMENDED INSTRUCTIONS FOR THE AFTERCARE OF PIERCINGS

Note: Your piercer's instructions may vary from these

  • Treat your new piercing as an open wound. Keep it clean. Body piercings need to be cleaned once or twice daily, every day, for the entire initial healing time.
  • Do not touch healing piercings with dirty hands.
  • Before cleanings, wash hands thoroughly with soap and warm water.
  • Rinse or soak the pierced area with warm water to remove any stubborn crust using a cotton swab and warm water.
  • Apply a small handful of mild antibacterial soap to the area with your clean hands.
  • Cleanse the area and the jewelry, and gently rotate the jewelry back and forth a few times to work the soap to the inside.
  • Allow the solution to remain there for a minute. Bathe normally; don't purposely work anything other than the cleanser onto the inside of the piercing.
  • Rinse the area thoroughly under running water, while rotating the jewelry back and forth to completely remove the cleanser from the inside and outside of the piercing.
  • Gently pat dry with disposable paper products such as gauze or tissues, as cloth towels can harbor bacteria. 
  • Consult a health care provider for:
  • (a) unexpected redness, tenderness or swelling at the site of the piercing
  • (b) rash
  • (c) unexpected drainage at or from the site of the piercing
  • (d) fever within 24 hours of the piercing 

CLIENT CONSENT

I have read and understand the above information


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


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 piercing 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

(b) rash

(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: December 21, 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*
Proof of parentage or legal guardianship required; e.g. minor's birth certificate, court order of guardianship. In addition, notarized document specifying consent to piercing procedure if parent not present. I have read and understand the above information. I consent to the piercing procedure as described above for my child.


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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