Angelina’s Rose LLC Disclosure
Angelina’s Rose LLC
222 Holiday Drive Suite 20
WRJ, VT 05001
(603)359-6002
All clients must sign and receive a copy of this form, prior to any modification procedure.
With more than 10 years of experience in the body modification industry specializing in microdermal piercings and traditional methods of ear stretching we are proud and happy to serve your body modification needs with highest standard of body jewelry, cleanliness, and professionalism!!
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As with any invasive procedure, body piercing may involve possible health risks. These risks may include:
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Pain
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Bleeding
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Infection
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Swelling
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Scarring of the area; and
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Nerve damage
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Unsterile equipment and needles can spread infectious diseases; it is extremely important to be sure that all equipment is clean and sanitary before use.
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You may not be allowed to donate blood either temporarily or permanently.
The piercing practitioner should:
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Properly and thoroughly cleanse the area before the procedure.
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Use sterilized equipment.
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Use sterile techniques.
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Provide information on the aftercare of the area receiving a piercing
HEALTH HISTORY
The following conditions may increase health risks associated with receiving any form of body art.
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Diabetes
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Hemophilia (bleeding)
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Skin diseases, lesions, or skin sensitivities to soaps, disinfectants etc.
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History of allergies or adverse reactions to pigments, dyes, or other sensitivities
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History of epilepsy, seizures, fainting, or narcolepsy
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Use of medications such as anticoagulants (such as coumadin), which thin the blood and/or interfere with blood clotting and;
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Hepatitis or HIV infection
RECOMMENDED INSTRUCTIONS FOR THE AFTERCARE OF PIERCINGS
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Treat your new piercing as an open wound. Keep it clean. Body piercings need to be cleaned once or twice daily, every day, for the entire initial healing time.
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Do not touch healing piercings with dirty hands.
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Before cleanings, wash hands thoroughly with soap and warm water.
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Rinse or soak the pierced area with warm water to remove any stubborn crust using a cotton swab and warm water.
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Apply a small handful of mild antibacterial soap to the area with you clean hands.
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Cleanse the area and the jewelry, rinse with saline.
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Bathe normally, don’t purposely work anything other than saline onto the inside of the piercing.
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Gently pat dry with disposable paper products such as gauze or paper towel, as cloth towels can harbor bacteria.
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Avoid prolonged use of band aids to avoid the blockage of air circulation
Consult a health care provider for:
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Unexpected redness, tenderness or swelling at the site of the piercing
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Rash
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Unexpected drainage at or from the piercing
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Fever within 24 hours of the piercing
DESCRIPTION OF BODY ART (To be completed by piercer)
CLIENT CONSENT
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I have read the above information.
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I have been advised and directed to the Infection Control Practices of this establishment and the Definitions of Unprofessional Conduct that comply with the OPR.
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I agree to inform the piercing practitioner of any chronic medical or communicable conditions.
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I agree to adhere to the exposure control plan of this establishment as pertains to clients.
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I am not under the influence of drugs or alcohol.
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I consent to the performance of the piercing procedure and have been given verbal and written instructions for aftercare as required by the Vermont Office of Professional Regulation.
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I agree to provide valid required identification and documentation.
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My information will be kept confidential.
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A copy of this document will be provided to me.
To file a complaint
Please contact the
Office of Professional Regulation:
or
Office Hours:
7:45 to 4:30, Monday through Friday
(Except Holidays)
802-828-1505