Let us do this part
Thu Jul 2 2020 05:49
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Our goal is to be inclusive, fun, clean, informative and perform a service to the best of our abilities. Thank you for choosing us.
Please read & answer
We’re not doctors
I FULLY UNDERSTAND THAT ANY EMPLOYEE< AGENT OR CONTRACTOR of Cereal City Tattoo & Piercing Llc when performing a tattoo does not act in the capacity of a medical processional. The suggestions made by any employee, agent or contractor of Cereal City Tattoo & Piercing Llc are just suggestions. They are not to be construed or substituted for advice from a medical professional.
I HEREBY RELEASE Cereal City Tattoo & Piercing Llc & its employees, agents and contractors, from all manner of liabilities, claims, action & demands, in law or in equity, which. I or my heirs have or got have now or hereafter by reason of complying with my request to be tattooed.
I hereby assume full responsibility for my aftercare & cleanliness. I UNDERSTAND that by having this tattoo performed that I am making a permanent change to my body & no claims have or will be made regarding the ability to undo the permanent changes I am requesting be made
To ensure proper healing of my tattoo & to prevent contracting any type of infection or illness (including, but not limited to MRSA & CoVid-19), I AGREE to stringently follow the aftercare suggestions outlines into the written tattoo aftercare instructions provided to me until the healing process is complete. I UNDERSTAND that a tattoo usually takes 2 weeks or longer to heal.
I UNDERSTAND that by having this tattoo performed that i am making a permanent change to my body & no claims have or will be made regarding the ability to undo the permanent changes I am requesting be made.
Have you eaten in the past 4hrs? It's a good idea to before hand to increase your blood sugar levels.
Do you have any conditions which may affect blood circulation, ability to heal, or fight infection?
Do you have any history of epilepsy, seizures, fainting or narcolepsy?
I UNDERSTAND neither the Artist nor Cereal City Tattoo & Piercing Llc is responsible for the meaning or spelling of the symbol, dates or text that I have provided to them or chosen from the flash (design) sheets.
M.D.H.H.S. Disclosure Statement
I have received a copy of M.D.H.H.S. Disclosure Statement /Notice for Filing Complaints
Public Act 375, which was enacted in December of 2010, indicates that individuals shall not tattoo, brand, or perform body piercing on another individual unless the tattooing, branding, or body piercing occurs at a body art facility licensed by the Michigan Department of Community Health. Body art facilities are required to be in compliance with the “Requirements for Body Art Facilities,” which provide guidelines for safe and sanitary body art administration.
As with any invasive procedure, body art may involve possible health risks. These risks may include, but are not limited to: transmissions of bloodborne diseases such as HIV and viral hepatitis, skin disorders, skin infections, and allergic reactions.
In addition, persons with certain conditions including, but not limited to, diabetes, hemophilia or epilepsy, are at a higher risk for complications and should consult a physician before undergoing a body art procedure.
If you wish to file a complaint against a body art facility related to compliance with PA 375 or have concerns about potential health risks, please visit www.michigan.gov/bodyart.
Do you have any history of hemophilia or excessive bleeding?
Have you had any alcoholic beverages or drugs in the last 8 hours?
Do you have to take antibiotics before seeing the dentist?
Have you taken any medications that thin the blood and/or interfere with blood clotting (including aspirin, Tylenol, and Ibuprofen) within the last 24 hours?
Do you have an history of allergies or adverse reactions to latex, pigments, dyes, disinfectants, metals or other sensitivities related to the tattoo procedure?
Do you have any other allergies? If yes what?
Pregnant or Breastfeeding?
Are you pregnant, have reason to believe you might be pregnant or breastfeeding?
I AFFIRM TO THE BEST OF MY KNOWLEDGE that I & members on my immediate family (&/or household) are not currently sick & in the last 30 days: have not been sick, have not been in contact with someone that is sick, & have not travelled outside of the country.
I UNDERSTAND that Cereal City Tattoo & Piercing Llc has put additional protective measures in place in order to further minimize the risk of exposure to any contamination, virus, or pathogen. I ALSO UNDERSTAND IT IMPOSSIBLE TO COMPLETELY ELIMINATE THAT RISK. I UNDERSTAND I WILL BE TATTOOED using appropriate sterile instruments & aseptic technique. I UNDERSTAND that getting tattooed does temporarily stress the body and the immune system, which could make me more susceptible to illness & infection. I ACCEPT THIS RISK. I WILLINGLY SUBMIT TO THESE PROCEDURES, with a full understanding of possible complications such as, but not limited to; infection, illness, allergic reaction, fading over time, or rejection of the ink.
Our CoVid-19 Preparedness and Response Guide is available by request.
I release all rights to any photographs taken of me and the tattoo and give consent in advance to their reproduction in print or electronic form. Including use in social media and advertising.
How did you hear about us?
If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.
I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or legal guardian is in complete understanding and concurrence with this agreement.
Date of birth:
If you are under
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Sign above or type signature:
I, as parent or legal guardian of the above minor under 18 years of age, hereby consent to the terms and conditions set forth in this release form
Based on the listed Michigan Public Health Code parent’s consent is required. MICHIGAN PUBLIC HEALTH CODE (EXCERPT) Act 368 of 1978 333.13102 Tattoo, brand, or body piercing on minor; consent and proof of authority of parent or guardian required. Sec. 13102. An individual shall not tattoo, brand, or perform body piercing on a minor unless the individual obtains the prior written informed consent of the minor's parent or legal guardian and proof of that individual's authority to give the informed consent required under this section. The minor's parent or legal guardian shall execute the written, informed consent required under this section in the presence of the licensee or an employee or agent of the licensee. The minor's parent or legal guardian shall present to the licensee or employee or agent of the licensee the minor's birth certificate or legal proof of guardianship to establish the individual's authority to give the informed consent required under this section. History: Add. 1996, Act 223, Eff. Sept. 1, 1996 ;-- Am. 2007, Act 149, Imd. Eff. Dec. 13, 2007 ;-- Am. 2010, Act 375, Imd. Eff. Dec. 22, 2010 Popular Name: Act 368 © 2020 Legislative Council, State of Michigan
Guardia'n legal name:
Natural guardian (birth parent)
Legal parent via marriage
Legal guardian via adoption
Other (provide proof)
If something happens, your emergency contact might need to explain your medical history, allergies, or medications.
Please take photo(s) of your government issued photo IDs and related paperwork.