15 Miss. Code. R. 19-60-11.5.10 - Consent Forms
1. A photocopy of
an original government-issued identification containing the date of birth of
the client shall be attached to the consent form. Consent forms shall be
maintained at the establishment for a minimum of two (2) years, shall be
produced and be made available at the request of the Department, and shall
contain, at a minimum, the following information:
a. Name of Tattooist or Body Piercer and
Department Certificate of Registration Number;
b. Name of supervisor, if the Tattooist or
Body Piercer has a Provisional Certificate of Registration;
c. Name and address of
Establishment;
d. Date of tattoo or
body piercing;
e. Name of
client;
f. Home address of
client;
g. Home telephone number of
client;
h. Sex of Client;
i. Date of Birth of client;
j. Description of location on the body to be
tattooed or pierced;
k.
Acknowledgment of the risks involved in a tattoo or body piercing;
l. Acknowledgment of the receipt of the
printed aftercare responsibilities of the client;
m. Statement that the client is not under the
influence of drugs or alcohol;
n.
Signature of the client;
o.
Signature of the Tattooist or Body Piercer; and
p. Signature of supervisor if
required.
2. The consent
form must contain a recommendation to the patron which states the Mississippi
State Board of Health recommends that any tattooing or piercing involving the
mucous membranes, such as the tongue or genitalia, be performed by a licensed
physician or oral surgeon as appropriate.
3. The consent form must contain a warning to
persons who are diabetic, HIV infected, or have End Stage Renal Disease that
they are at higher risk of complications and should consult their personal
physician prior to being tattooed or pierced.
4. The consent form must contain a warning to
patrons that tattooing or piercing of persons with preexisting cardiac
conditions, especially when piercing occurs on areas of the body involving the
mucous membranes, may result in bacteria in the blood stream which can further
damage the heart, and that such persons should seek permission from their
physician prior to the tattooing or piercing procedure.
Notes
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No prior version found.