Informed consent

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Name(*)

Surname(*)

Sex:(*)
MF

City of birth(*)

Date of birth:(*)

Resident in City(*)

Street:(*)

ZIP Code(*)

Country: (*)

Phone Number:(*)

E-mail(*)

Job:(*)

Identity document number:(*)

I DECLARE, ON MY OWN RESPONSIBILITY

  • Tattooing consist of introducing into the skin various kinds of permanent pigments, through sterile and disposable tools.
  • To remove a tattoo is necessary to resort to small or medium - scale surgery.
  • The operator is obliged to comply with the health and hygiene standards prescribed by Law, but sever infections, like Hepatits B and C or HIV can still be transmitted by tattoing or piercing.
  • You may be or may become allergic to metal.
  • A skin exposed to an ongoing inflammation can't be tattooed or pierced.
  • Tattoos and body piercings are to be considered permanent skin lesions; it is, therefore, important to carefully treat them with basic sanitary regulations as the ones peoples holds in the case of wounds excoriations, to prevent consecutive complications as inflammation or local infections.
  • Tattoos can unfit military standards for those wishing to pursue such a career.
  • Blood donations are forbidden within the following 4 months.



:FORM:

For a prorper executions of the tattoo piercing it is necessary that hte operator is informed of the client's health status, with the sole purpose to verify the existence, or not, of possible contraindications.
The following information will be safe and not accessible to any other.
So please check the boxes below and eventually tick the one that might correspond to your case.



HepatitisHivCoagulation disordersDiabetesRecent cortisone consumptionImmunodeficiencyAnti-platelet/anticoagulants disorders or drugs assumptionsCardiac disordersAngiomaPregnancies/breast-feedingRecent alcohol and/or drugs assumptionAllergies to any substance inside pigments or metals



Any other ongoing disease or disorders:

Others skin disease as:



Is it the first tattoo/piercing?(*)
YesNo

Is this your first tattoo with Sara?(*)
YesNo

Did you make any other recent (within 6 months) tattoo or piercing by another operator?(*)
YesNo

How did you find out about me?
InstagramFacebookPassaparolaOther

:SIDE EFFECTS:

  • The tattoo may come not identical to the one designed as it is, in any case, the result of a free-hand technique.
  • It might be necessary to repeat part of the treatment after 3-4 weeks as the area tattooed may be resistant to retain colors, therefore, the work could be partially fading or missing.
  • Swelling and redness of the treated area, for a few hours after the treatment, always occurs as normal side effects. Burning or tingling are destined to be reabsorbed and will disappear spontaneusly. The extent and duration of these phenomena can vary from subject to subject.

THE UNDERSIGNED DECLARES, THEREFORE:

to be have been informed in details of any risks related to tattooing or piercing, the precautions to be taken following the practice; to have recived written information, have reported any contraindication to this practice and have understood all the information provided. So:

I CONSENT TO THE EXECUTION OF THE TATTOO/PIERCING

Having as subject:

to be realized in this body part:

That you will do with the operator SARA LIVERANI


Privacy:

I consent to the processing of the personal data pursuant to art.23 of 196/2003 as well as in compliance with current European legislation (GDPR - Reg. U.E 2016/679), for the aforementioned purposes. I also declare that I took vision of the notice on the purposes and methods of processing sensitive data in accordance with art. 13 of the same Law. According to art. 10 and 320 of the Civil Code, and art. 96 and 97 of the Law 22.4.1941 no 633, on copyright, I authorize the free of charge publishing and / or distribution with no time limits and in any form of photos / images which partially or fully represent my person on the web, social networks, as well as in print and /or any other means for the sole purposes of advertising and promotion. I expressly authorize the conservation of photo / images as file in the operator's computer. I also consent to the use of photographs or images that partially or fully represent me before, during and after athe execution, for the purpose of professional documentation or as evidence, in case of any legal disputes.



Signature
Parent signature (in case of minor)