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Please carefully read and complete the following to the best of your knowledge.
Received a copy of the Disclosure Statement and Notice for Filing Complaints*
Received a copy of the Aftercare Information Sheet*
Completed the Client Health Questionnaire, and received any additional, applicable information
I acknowledge that I have received a copy of the Disclosure Statement and Notice for Filing Complaints, received a copy of the
Aftercare Information Sheet, and completed the Client Health Questionnaire and received any additional, applicable information.*
In addition, this record serves as signed documentation that the body art facility performing your tattoo, piercing, and/or branding is a
licensed facility by the State of Michigan. It is recommended that individuals or organizations visit www.michigan.gov/bodyart to
determine current the license status of the body art facility before proceeding with any body art procedure.*