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BODY ART CONSENT FORM


INFORMED CONSENT FORM

Although every precaution will be taken to ensure your safety and well-being before, during, and after your treatment/procedure, please be aware of the following information and possible risks and indicate that you fully understand what to expect. Please initial:

I hereby consent to and authorize the technician/esthetician to perform the following treatment/procedure: Body Art 


I voluntarily agree to undergo this treatment/procedure after the nature and purpose of this treatment/procedure has been explained to me, along with the risks and hazards involved. 


Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. 


I understand that it is imperative to my health and safety that I disclose all of the information requested in the Client Consultation/Health History form. I have cited all conditions and circumstances regarding my health history, allergies, and medications, supplements, or prescriptions being taken (orally and/or topically), and any past reactions to products or medications. 


I understand that no specific guarantees of the results can or have been made and that there is the possibility I may require additional treatments/procedures to obtain the expected results at an additional cost. 


I have read and understand all pre-treatment, post-treatment, and home care instructions. I understand the importance of following all instructions given to me. In the event that I have additional questions or concerns regarding my treatment or post-treatment care, I will consult the technician/esthetician immediately. I understand that if I choose to consult a physician, I do so at my own expense. 


I consent to “before-and-after” photographs for the purpose of documentation, potential advertising, and promotional purposes. 


I understand that if I have any concerns, I will address these with my technician/esthetician. I give permission to my technician/esthetician to perform the above treatment/procedure we have discussed and will hold him/her/them and his/her/their staff harmless and nameless from any liability that may result from this treatment/procedure. I understand my technician/esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs and that I have been provided sufficient opportunity for discussion and to have any questions answered. I understand the procedure and accept the risks. I do not hold the technician/esthetician, whose signature appears below, responsible for any of my conditions that were present but not disclosed at the time of this procedure that may be affected by the treatment performed today. 

Client Signature:

Date: August 1, 2026

PLEASE READ AND CHECK THE BOXES WHEN YOU ARE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SIGNING

In consideration of receiving BODY ART from (Name of Practitioner to be provided in the next section), the practitioner at (Name of Tattoo Business to be provided in the next section), (together with its employees, apprentices, and agents, the “Body Art Business”) I confirm the following by initialing each applicable item:

*CAUTION: Tattoo inks, dyes, and pigments that have not been approved by the federal Food and Drug Administration have health consequences that are unknown. 

I am not under the influence of alcohol or drugs and that I am voluntarily submitting myself to receive body art without duress or coercion.


I acknowledge that the information that I have provided in the medical questionnaire is complete and true to the best of my knowledge. 


I understand the permanent nature of receiving body art and that removal can be expensive and may leave scars on the procedure site. 


The body art described or shown on the client record form is correctly placed to my specifications. 


All questions about the body art procedure have been answered to my satisfaction, and I have been given written aftercare instructions for the procedure I am about to receive. 


I understand the restrictions on physical activities such as bathing, recreational water activities, gardening, contact with animals, and the durations of the restrictions. 


I understand that any medical information obtained will be subject to the federal Health Insurance Portability and Accountability Act of 1996 (HIPPA). 


I am aware that tattoo inks, dyes, and pigments used on the procedure site have not been approved by the federal Food and Drug Administration, and that the health consequences of using these products are unknown. 


I am aware of the signs and symptoms of infection, including, but not limited to redness, swelling, tenderness of the procedure site, red streaks going from the procedure site towards the heart, elevated body temperature, or purulent drainage from the procedure site. 


I understand there is a possibility of getting an infection as a result of receiving body art particularly in the event that I do not take proper care of the procedure site. 


I will seek professional medical attention if signs and symptoms of infection occur. 


I agree to follow all instructions concerning the care of my tattoo, and that any touch-ups needed due to my own negligence will be done at my own expense. 


I understand that there is a chance I might feel lightheaded, dizzy during or after being tattooed. 


I agree to immediately notify the artist in the event I feel lightheaded, dizzy and/or faint before, during or after the procedure. 


I agree to release and forever discharge and forever hold harmless Beauty Realm 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 body art or the procedures and conduct used to apply my body art and any and all body art applied by Beauty Realm and its associates, agents and representative in the future.


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.

Signed:

 

Date: August 1, 2026


POLICY CONSENT

Rescheduling & Cancellations

You are responsible for rescheduling or canceling your appointment via the booking app link sent to you by text. If you are experiencing technical issues, please text Jacky at 719-297-1447.

No charges for rescheduling if done 48 hours prior to your appointment time. 


Children Policy

To fully enjoy your experience, please leave children at home unless they are being serviced. Enjoy your self-care! 


Consent Forms

After your booking is confirmed, please visit the main page of my website and click the menu bar (top right-hand corner). Select the drop-down menu, proceed to select the consent form for your treatment. Forms must be completed at least 6-8 hours prior to your treatment time. 


Arrival Instructions

Upon arrival, find Jacky’s doorbell by the reception desk. Please have a seat and wait for your name to be called. You are welcome to use the restrooms within the facility. 


Conduct Policy

Disrespectful behavior will not be tolerated. You may be dropped as a future client if Jacky feels uncomfortable or unsafe. 


Tardiness

Appointments are subject to rescheduling and additional fees if you are more than 10 minutes late. 


Cancellation Fees

  • Late cancellation (less than 48 hours): 50% of service total
  • Same-day rescheduling/cancellation: 50% of service total
  • No-show/no-call: 100% of service total

No-shows or no-calls may result in being dropped as a future client. 


Refunds & Satisfaction Policy

Please note that no refunds will be issued for services rendered. However, your satisfaction is very important to me. If you are dissatisfied with your service, please contact me directly as soon as possible. I will work with you to address your concerns and ensure you are comfortable with your results. I am committed to providing an excellent experience and will make every effort to resolve any issues.


Retail Item Policy

All retail sales are final and non-refundable. However, if you are not completely satisfied with your purchase, I am happy to offer an even exchange for another product of equal value. Please contact Jacky within 7 days of purchase to initiate the exchange. Items must be unused, unopened, and in original condition to qualify for an exchange. 



Beauty Realm LLC
(719) 297-1447

First Client's Name
First Name*
Middle Name
Last Name*
Phone*
Select Gender
First Client's Date of Birth*
Date of Birth
Information
Please choose the following ... *
I am the person on the legal ID presented as proof that I am at least 18 years of age.
I am under the age of 18 years old and have the presence of my parent or guardian to receive the body piercing (Applicable only to underage body piercing).
Please check any conditions listed below that apply to you.
ALLERGIC TO ANTIBIOTICS
ALLERGIC TO LATEX
ASTHMA
BLOOD THINNERS
DIABETES
ECZEMA/PSORIASIS
EPILEPSY
FAINTING OR DIZZINESS
GONORRHEA/SYPHILIS
HEART CONDITION
HEMOPHILIA
HEPATITIS
HERPES
HIV
MRSA/STAPH INFECTION
PREGNANT/NURSING
SCARRING/KELOIDING
SKIN CONDITIONS
OTHER*
*If you checked other, please state the condition.
How long has it been since you last ate?
Do you have any allergies such as metals, soaps, cosmetics or alcohol?
Do you use any medications that might affect the healing of the body art you wish to receive?
Do you have any other medical or skin conditions that may affect the outcome of your procedure?
Have you ever been prescribed antibiotics prior to dental or surgical procedures?
Do you have any cardiac valve disease?
Is there any other information you feel you should provide to the body art practitioner?

The information I have provided is complete and true to the best of my knowledge.

First Client's Signature*
Second Client's Name
First Name*
Middle Name
Last Name*
Select Gender
Client's Date of Birth*
Date of Birth
Information
Please choose the following ... *
I am the person on the legal ID presented as proof that I am at least 18 years of age.
I am under the age of 18 years old and have the presence of my parent or guardian to receive the body piercing (Applicable only to underage body piercing).
Please check any conditions listed below that apply to you.
ALLERGIC TO ANTIBIOTICS
ALLERGIC TO LATEX
ASTHMA
BLOOD THINNERS
DIABETES
ECZEMA/PSORIASIS
EPILEPSY
FAINTING OR DIZZINESS
GONORRHEA/SYPHILIS
HEART CONDITION
HEMOPHILIA
HEPATITIS
HERPES
HIV
MRSA/STAPH INFECTION
PREGNANT/NURSING
SCARRING/KELOIDING
SKIN CONDITIONS
OTHER*
*If you checked other, please state the condition.
How long has it been since you last ate?
Do you have any allergies such as metals, soaps, cosmetics or alcohol?
Do you use any medications that might affect the healing of the body art you wish to receive?
Do you have any other medical or skin conditions that may affect the outcome of your procedure?
Have you ever been prescribed antibiotics prior to dental or surgical procedures?
Do you have any cardiac valve disease?
Is there any other information you feel you should provide to the body art practitioner?

The information I have provided is complete and true to the best of my knowledge.

Third Client's Name
First Name*
Middle Name
Last Name*
Select Gender
Client's Date of Birth*
Date of Birth
Information
Please choose the following ... *
I am the person on the legal ID presented as proof that I am at least 18 years of age.
I am under the age of 18 years old and have the presence of my parent or guardian to receive the body piercing (Applicable only to underage body piercing).
Please check any conditions listed below that apply to you.
ALLERGIC TO ANTIBIOTICS
ALLERGIC TO LATEX
ASTHMA
BLOOD THINNERS
DIABETES
ECZEMA/PSORIASIS
EPILEPSY
FAINTING OR DIZZINESS
GONORRHEA/SYPHILIS
HEART CONDITION
HEMOPHILIA
HEPATITIS
HERPES
HIV
MRSA/STAPH INFECTION
PREGNANT/NURSING
SCARRING/KELOIDING
SKIN CONDITIONS
OTHER*
*If you checked other, please state the condition.
How long has it been since you last ate?
Do you have any allergies such as metals, soaps, cosmetics or alcohol?
Do you use any medications that might affect the healing of the body art you wish to receive?
Do you have any other medical or skin conditions that may affect the outcome of your procedure?
Have you ever been prescribed antibiotics prior to dental or surgical procedures?
Do you have any cardiac valve disease?
Is there any other information you feel you should provide to the body art practitioner?

The information I have provided is complete and true to the best of my knowledge.

Fourth Client's Name
First Name*
Middle Name
Last Name*
Select Gender
Client's Date of Birth*
Date of Birth
Information
Please choose the following ... *
I am the person on the legal ID presented as proof that I am at least 18 years of age.
I am under the age of 18 years old and have the presence of my parent or guardian to receive the body piercing (Applicable only to underage body piercing).
Please check any conditions listed below that apply to you.
ALLERGIC TO ANTIBIOTICS
ALLERGIC TO LATEX
ASTHMA
BLOOD THINNERS
DIABETES
ECZEMA/PSORIASIS
EPILEPSY
FAINTING OR DIZZINESS
GONORRHEA/SYPHILIS
HEART CONDITION
HEMOPHILIA
HEPATITIS
HERPES
HIV
MRSA/STAPH INFECTION
PREGNANT/NURSING
SCARRING/KELOIDING
SKIN CONDITIONS
OTHER*
*If you checked other, please state the condition.
How long has it been since you last ate?
Do you have any allergies such as metals, soaps, cosmetics or alcohol?
Do you use any medications that might affect the healing of the body art you wish to receive?
Do you have any other medical or skin conditions that may affect the outcome of your procedure?
Have you ever been prescribed antibiotics prior to dental or surgical procedures?
Do you have any cardiac valve disease?
Is there any other information you feel you should provide to the body art practitioner?

The information I have provided is complete and true to the best of my knowledge.

Fifth Client's Name
First Name*
Middle Name
Last Name*
Select Gender
Client's Date of Birth*
Date of Birth
Information
Please choose the following ... *
I am the person on the legal ID presented as proof that I am at least 18 years of age.
I am under the age of 18 years old and have the presence of my parent or guardian to receive the body piercing (Applicable only to underage body piercing).
Please check any conditions listed below that apply to you.
ALLERGIC TO ANTIBIOTICS
ALLERGIC TO LATEX
ASTHMA
BLOOD THINNERS
DIABETES
ECZEMA/PSORIASIS
EPILEPSY
FAINTING OR DIZZINESS
GONORRHEA/SYPHILIS
HEART CONDITION
HEMOPHILIA
HEPATITIS
HERPES
HIV
MRSA/STAPH INFECTION
PREGNANT/NURSING
SCARRING/KELOIDING
SKIN CONDITIONS
OTHER*
*If you checked other, please state the condition.
How long has it been since you last ate?
Do you have any allergies such as metals, soaps, cosmetics or alcohol?
Do you use any medications that might affect the healing of the body art you wish to receive?
Do you have any other medical or skin conditions that may affect the outcome of your procedure?
Have you ever been prescribed antibiotics prior to dental or surgical procedures?
Do you have any cardiac valve disease?
Is there any other information you feel you should provide to the body art practitioner?

The information I have provided is complete and true to the best of my knowledge.

Sixth Client's Name
First Name*
Middle Name
Last Name*
Select Gender
Client's Date of Birth*
Date of Birth
Information
Please choose the following ... *
I am the person on the legal ID presented as proof that I am at least 18 years of age.
I am under the age of 18 years old and have the presence of my parent or guardian to receive the body piercing (Applicable only to underage body piercing).
Please check any conditions listed below that apply to you.
ALLERGIC TO ANTIBIOTICS
ALLERGIC TO LATEX
ASTHMA
BLOOD THINNERS
DIABETES
ECZEMA/PSORIASIS
EPILEPSY
FAINTING OR DIZZINESS
GONORRHEA/SYPHILIS
HEART CONDITION
HEMOPHILIA
HEPATITIS
HERPES
HIV
MRSA/STAPH INFECTION
PREGNANT/NURSING
SCARRING/KELOIDING
SKIN CONDITIONS
OTHER*
*If you checked other, please state the condition.
How long has it been since you last ate?
Do you have any allergies such as metals, soaps, cosmetics or alcohol?
Do you use any medications that might affect the healing of the body art you wish to receive?
Do you have any other medical or skin conditions that may affect the outcome of your procedure?
Have you ever been prescribed antibiotics prior to dental or surgical procedures?
Do you have any cardiac valve disease?
Is there any other information you feel you should provide to the body art practitioner?

The information I have provided is complete and true to the best of my knowledge.

Seventh Client's Name
First Name*
Middle Name
Last Name*
Select Gender
Client's Date of Birth*
Date of Birth
Information
Please choose the following ... *
I am the person on the legal ID presented as proof that I am at least 18 years of age.
I am under the age of 18 years old and have the presence of my parent or guardian to receive the body piercing (Applicable only to underage body piercing).
Please check any conditions listed below that apply to you.
ALLERGIC TO ANTIBIOTICS
ALLERGIC TO LATEX
ASTHMA
BLOOD THINNERS
DIABETES
ECZEMA/PSORIASIS
EPILEPSY
FAINTING OR DIZZINESS
GONORRHEA/SYPHILIS
HEART CONDITION
HEMOPHILIA
HEPATITIS
HERPES
HIV
MRSA/STAPH INFECTION
PREGNANT/NURSING
SCARRING/KELOIDING
SKIN CONDITIONS
OTHER*
*If you checked other, please state the condition.
How long has it been since you last ate?
Do you have any allergies such as metals, soaps, cosmetics or alcohol?
Do you use any medications that might affect the healing of the body art you wish to receive?
Do you have any other medical or skin conditions that may affect the outcome of your procedure?
Have you ever been prescribed antibiotics prior to dental or surgical procedures?
Do you have any cardiac valve disease?
Is there any other information you feel you should provide to the body art practitioner?

The information I have provided is complete and true to the best of my knowledge.

Eighth Client's Name
First Name*
Middle Name
Last Name*
Select Gender
Client's Date of Birth*
Date of Birth
Information
Please choose the following ... *
I am the person on the legal ID presented as proof that I am at least 18 years of age.
I am under the age of 18 years old and have the presence of my parent or guardian to receive the body piercing (Applicable only to underage body piercing).
Please check any conditions listed below that apply to you.
ALLERGIC TO ANTIBIOTICS
ALLERGIC TO LATEX
ASTHMA
BLOOD THINNERS
DIABETES
ECZEMA/PSORIASIS
EPILEPSY
FAINTING OR DIZZINESS
GONORRHEA/SYPHILIS
HEART CONDITION
HEMOPHILIA
HEPATITIS
HERPES
HIV
MRSA/STAPH INFECTION
PREGNANT/NURSING
SCARRING/KELOIDING
SKIN CONDITIONS
OTHER*
*If you checked other, please state the condition.
How long has it been since you last ate?
Do you have any allergies such as metals, soaps, cosmetics or alcohol?
Do you use any medications that might affect the healing of the body art you wish to receive?
Do you have any other medical or skin conditions that may affect the outcome of your procedure?
Have you ever been prescribed antibiotics prior to dental or surgical procedures?
Do you have any cardiac valve disease?
Is there any other information you feel you should provide to the body art practitioner?

The information I have provided is complete and true to the best of my knowledge.

Ninth Client's Name
First Name*
Middle Name
Last Name*
Select Gender
Client's Date of Birth*
Date of Birth
Information
Please choose the following ... *
I am the person on the legal ID presented as proof that I am at least 18 years of age.
I am under the age of 18 years old and have the presence of my parent or guardian to receive the body piercing (Applicable only to underage body piercing).
Please check any conditions listed below that apply to you.
ALLERGIC TO ANTIBIOTICS
ALLERGIC TO LATEX
ASTHMA
BLOOD THINNERS
DIABETES
ECZEMA/PSORIASIS
EPILEPSY
FAINTING OR DIZZINESS
GONORRHEA/SYPHILIS
HEART CONDITION
HEMOPHILIA
HEPATITIS
HERPES
HIV
MRSA/STAPH INFECTION
PREGNANT/NURSING
SCARRING/KELOIDING
SKIN CONDITIONS
OTHER*
*If you checked other, please state the condition.
How long has it been since you last ate?
Do you have any allergies such as metals, soaps, cosmetics or alcohol?
Do you use any medications that might affect the healing of the body art you wish to receive?
Do you have any other medical or skin conditions that may affect the outcome of your procedure?
Have you ever been prescribed antibiotics prior to dental or surgical procedures?
Do you have any cardiac valve disease?
Is there any other information you feel you should provide to the body art practitioner?

The information I have provided is complete and true to the best of my knowledge.

Tenth Client's Name
First Name*
Middle Name
Last Name*
Select Gender
Client's Date of Birth*
Date of Birth
Information
Please choose the following ... *
I am the person on the legal ID presented as proof that I am at least 18 years of age.
I am under the age of 18 years old and have the presence of my parent or guardian to receive the body piercing (Applicable only to underage body piercing).
Please check any conditions listed below that apply to you.
ALLERGIC TO ANTIBIOTICS
ALLERGIC TO LATEX
ASTHMA
BLOOD THINNERS
DIABETES
ECZEMA/PSORIASIS
EPILEPSY
FAINTING OR DIZZINESS
GONORRHEA/SYPHILIS
HEART CONDITION
HEMOPHILIA
HEPATITIS
HERPES
HIV
MRSA/STAPH INFECTION
PREGNANT/NURSING
SCARRING/KELOIDING
SKIN CONDITIONS
OTHER*
*If you checked other, please state the condition.
How long has it been since you last ate?
Do you have any allergies such as metals, soaps, cosmetics or alcohol?
Do you use any medications that might affect the healing of the body art you wish to receive?
Do you have any other medical or skin conditions that may affect the outcome of your procedure?
Have you ever been prescribed antibiotics prior to dental or surgical procedures?
Do you have any cardiac valve disease?
Is there any other information you feel you should provide to the body art practitioner?

The information I have provided is complete and true to the best of my knowledge.

Additional Information
Name of Practitioner:
Name of Tattoo Business:
ID of Client or of Parent or Guardian (if Client is underage) *
  
Valid file types: JPG, GIF, PNG, and PDF
Parent or Guardian's Driver's License / ID Card
Driver's License / ID Card Number*
Issuing State*
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Emergency Contact's Relation to Participant
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
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*
Middle Name
Last Name*
Phone*
Select Gender
Parent or Guardian's Date of Birth*
Date of Birth
Information
Please choose the following ... *
I am the person on the legal ID presented as proof that I am at least 18 years of age.
I am under the age of 18 years old and have the presence of my parent or guardian to receive the body piercing (Applicable only to underage body piercing).
Please check any conditions listed below that apply to you.
ALLERGIC TO ANTIBIOTICS
ALLERGIC TO LATEX
ASTHMA
BLOOD THINNERS
DIABETES
ECZEMA/PSORIASIS
EPILEPSY
FAINTING OR DIZZINESS
GONORRHEA/SYPHILIS
HEART CONDITION
HEMOPHILIA
HEPATITIS
HERPES
HIV
MRSA/STAPH INFECTION
PREGNANT/NURSING
SCARRING/KELOIDING
SKIN CONDITIONS
OTHER*
*If you checked other, please state the condition.
How long has it been since you last ate?
Do you have any allergies such as metals, soaps, cosmetics or alcohol?
Do you use any medications that might affect the healing of the body art you wish to receive?
Do you have any other medical or skin conditions that may affect the outcome of your procedure?
Have you ever been prescribed antibiotics prior to dental or surgical procedures?
Do you have any cardiac valve disease?
Is there any other information you feel you should provide to the body art practitioner?

The information I have provided is complete and true to the best of my knowledge.

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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