Body Art Consent Form

BLACK RIVER TATTOO CONVENTION

JUNE 27, 28 & 29, 2025

Located at the Blue Water Convention Center

800 Harker Street, Port Huron, Michigan 48060

(810)385-2222 ~ BlackRiverTattooConvention@gmail.com

First name

Last name

Phone

Birthday

Month

Day

Year

Are you over the age of 18 years old? *No minor tattooing is allowed at this event, even with parental consent

Multi-line address

Country/Region

Address

City

Zip / Postal code

Please enter the name of the artist performing the procedure. *please check with them for the correct spelling*

Please enter the booth number for your artist. *Please check with the artist for the correct booth number*

Please describe the body location in detail of where you are placing the tattoo.

Please describe what the tattoo is that you are getting. *Please be specific*

Please upload a photo of your government I.D.

I understand that Coronavirus has a long incubation period and carriers may be asymptomatic. Without medical testing, it is impossible to determine who has the virus.

Symptoms of Covid-19 include:

Fever Dry cough Difficulty breathing

Loss of sense of taste or smell

Runny nose Sore throat Shortness of breath

I confirm that I am not presenting with any of the above symptoms.

I confirm that in the past 14 days I have not experienced a fever greater than 100.4F OR symptoms of lower respiratory illness such as a cough, shortness of breath, difficulty breathing or sore throat.

I confirm that in the last 14 days I have not come into close contact with anyone with a laboratory confirmed Covid-19 diagnosis.

I confirm that in the past 14 days I have not come into close contact with someone with a fever greater than 1004 F OR other symptoms.

I confirm that I am not living with or caring for someone with Covid-19.

I confirm that I, as well as all household members, have not been diagnosed with Covid-19.

I confirm that I have not traveled outside the country or to a city that is considered a hot spot

within the last 14 days.

I understand that Black River Tattoo Convention or it's practitioners cannot be held liable for any exposure to the virus caused by any information on this form, changing safety recommendations from local, State or Federal authorities or the health histories provided by each client.

By signing below I agree to the above statements and release Black River Tattoo Convention and its practitioners from any and all liability for the unintentional exposure or harm caused by Covid-19.

I have not had any symptoms or recent exposures to covid-19.*

Yes, I do NOT have any symptoms currently.

Health Questionnaire. Only select if you do currently have any of the following conditions. If you do not have any of the listed conditions check the last "NONE" option.*

History of hemophilia or excessive bleeding?

Diabetes or other conditions which may affect blood circulation and/or ability to fight infection?

History of skin disease, skin lesions, or skin sensitivities to soaps or disinfectants?

History of allergies or adverse reactions to latex, pigments, dyes, disinfectants, metals or other sensitivities related to body art procedures?

History of epilepsy, seizures, fainting or narcolepsy?

Treatment with anticoagulants or other medications that thin the blood and/or interfere with blood clotting?

Current pregnancy and/or breast-feeding?

NONE. I do not have any of the above conditions.

Please state any other information that would aid the body art technician or any other individual involved in providing education on your suitability for receiving a body art procedure.

I acknowledge that the body art procedure will result in a permanent change to my appearance and that my skin may not be restored to its pre existing condition even after the procedure is healed.

Yes, I understand.

I acknowledge that I have been given adequate opportunity to read and understand this document, that it was not presented to me at the last minute, and I understand that I am signing a legal contract

Yes, I understand.

I accept the risks, associated with body art. These risks, known and unknown, can lead to injury, including but not limited to infection, scarring, keloiding and allergic reactions.

Yes, I understand.

I agree to follow the aftercare instructions given to me both verbally and in written form on this document.

Yes, I understand.

Use of Numbing Products

The use of products to numb the skin prior to any body art procedure is illegal and prohibited. The risks involved in using such products may include: adverse reactions, trouble healing, infection, scarring and can cause life threatening side effects including but not limited to irregular heartbeat, seizures and in rare cases may be fatal. I acknowledge that the use of these products are illegal and prohibited. I agree to not hold Black River Tattoo Convention or any practitioner performing the work liable for any or all damages that may occur if I choose to ignore the law and choose to use such products without the knowledge of the practitioner.

I understand choosing to use numbing products prior too, during or after the procedure is illegal and prohibited, I accept the risks involved in the use of said products.

Yes, I understand.

I affirm that I MAY be allowed, to donate blood within the standard deferral period, if I present a copy of this client record provided by the body art facility to the blood donor facility.

Yes, I understand.

Aftercare Instructions

Procedure Type: TATTOO

Approximate Healing Time: Two to four (2-4) weeks or longer.

Supplies Needed: Fragrance Free and Dye Free Mild Soap + mild skin lotion or ointment.

Aftercare Instructions:

Keep your new tattoo bandaged for approximately two (2) hours. 12-48 hours if using a transparent film style bandage. Then carefully remove bandage and wash entire area with mild soap and cool water. Allow soap lather to sit on site for 2-3 minutes. Rinse then dry the area, once dry apply a thin layer of mild skin lotion/ointment as needed. Use only a very thin coating and continue to re-apply it two-four (2-4) times daily for at least three (3) days. Wash tattoo before applying new lotion/ointment. Do not re-bandage the tattoo, as it could stick to the bandage and damage or loss of color can occur.

Additional Considerations:

Wash your hands often and before cleaning your tattoo. Avoid sunburn(wrap tattoo area loosely with a bandanna or similar fabric to protect it from the sun), salt or chlorine water, beaches or hot tubs until your tattoo is completely healed. In the event of mild scabs occur, do not pick at or attempt to “wash off” the scab. Allow it to heal by itself. You may apply a mild skin lotion to keep “flaking/peeling” to a minimum. If your tattoo is in a high movement area you may use a Sterile Non-Stick Bandage and medical tape to protect the tattoo during high risk times (workplaces, hospitals, etc). Avoid using products with high petroleum levels such as Vitamin A&D Ointment, Neosporin, Vaseline or ANY product not specifically designed to heal tattoos. Always clean and change your bedding daily. Do not wrap your tattoo with Saran Wrap or any other food preserving products

I agree, and fully understand these aftercare instructions. I will reach out to my artist with any questions or concerns I may have during the healing of the tattoo procedure.*

Yes, I understand.

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.

Release of Liability

Release of Liability in consideration for the services performed to the undersigned by above artist & Black River Tattoo Convention(BRTC). The undersigned hereby agrees to: Fully and completely release from any and all liability which may result to the undersigned as a result of services performed by above artist & BRTC. The request of an on behalf of the said undersigned services include cosmetic and decorative permanent tattooing done at the request of the undersigned by above artist & BRTC. By signing this release, the undersigned also represents to above artist & BRTC. that the said person is at least 18 years of age and has fully and thoughtfully contemplated the nature and extent of the services to be performed at the undersigned’s request by above artist & BRTC. Including the permanent nature of the tattoo work and all-inherent risks associated with the application of a tattoo and its permanent effect. The undersigned further acknowledges and agrees, covenants and contracts with above artist & BRTC. To fully release him/her from any and all liability of whatsoever kind and nature, including medical expenses which the undersigned may incur as a result of the application and permanent effect of the tattoo requested to be performed above artist & BRTC. Also hereby agrees to release, indemnify and hold above artist & BRTC harmless from any and all liability which above artist & BRTC may be exposed to as a result of actions brought by or on behalf of the undersigned, his/her heirs or assigns, or legal representatives.

I understand and release any and all liability from the company or the practitioner

Yes, I understand.

By signing below, I affirm that I understand and agree to all statements on this form. Also, that all the information I provided on this form are true and correct.*

Signature field is empty.