Tattoo/Body Piercing Artist - Mississippi State Department of Health

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Inspected by:NameTitleFollow-up required: yes no(If yes, explain)Return date for follow-up inspectionPASSED INSPECTION:SignatureDateTitleFAILED INSPECTION:SignatureDateCOMMENTS:Title
CONSENT FOR BODY PIERCING/TATTOOName of EstablishmentAddressCity, State, ZipPatron Information (Copy of government-issued identification must be attached to this form)NameAddressPhoneSex: ” Male ” FemaleAge________ Date of BirthI have read and understand the following:1. I am at least 18 years old.2. I am not under the influence of alcohol or drugs.3. I have received a printed statement of aftercare instructions4. I have been informed by the registrant and acknowledge the risks involved in getting a tattoo or body piercing5. The Mississippi State Department of Health recommends that any tattooing or piercing involving the mucousmembranes, such as the tongue or genitalia, be performed by a licensed physician or oral surgeon asappropriate.WARNINGS:Persons who may be immunocompromised (included but not limited to those with End Stage Renal Disease, diabetes orHIV infection) should consult their personal physician prior to being tattooed or pierced.Persons with a pre-existing cardiac condition, especially when piercing occurs on areas of the body involving the mucousmembranes, may result in bacteria in the blood stream which can further damage the heart, and that such persons shouldseek permission from their personal physician prior to receiving a piercing or tattoo.Signature of PatronDateBody Piercer/Tattoo Artist InformationName of Artist Registration #Name of Supervisor Registration #(if Artist holds a Provisional Registration)Signature of ArtistSignature of Supervisor(if Artist holds a Provisional Registration)Body Piercing InformationDescription of PiercingLocation of PiercingPriceTattoo InformationDescription of TattooLocation of TattooPrice
Page 1 and 2: Dear Applicant:Enclosed you will fi
Page 3: qqTattoo ArtistBody PiercingMISSISS
Page 6 and 7: qqTattoo ArtistBody PiercingOffice
Page 8 and 9: Supervision Agreement for Provision
Page 12 and 13: Regulations Governing Registrationo
Page 14 and 15: Rule 11.5.4 Piercing Equipment ....
Page 17 and 18: Subchapter 3: Requirements for Cert
Page 19 and 20: the Department, in its discretion,
Page 21 and 22: patron. Any dye in which the needle
Page 23 and 24: on an individual client. Under no c
Page 25 and 26: Hands shall be washed prior to donn
Page 27 and 28: e. Name of client;f. Home address o
Page 29 and 30: Rule 11.5.15 Summary Suspension: Th
Page 31 and 32: 3. That the Registrant shall have t
Page 33: Rule 11.7.4 Administrative Grievanc

Tattoo/Body Piercing Artist - Mississippi State Department of Health

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