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For Office Use Only

(Printed Name of Licensed Salon)

(Printed Name of Tattoo Artist)

(Signature of Tattoo Artist)

State of Florida Department of Health

Authority 381.00789, Florida Statutes

Tattoo Notarized Minor Consent Form

State of FloridaCounty of

(Print Name of Parent or Legal Guardian)

Residing at:

Hereby swears or affirms under penalty of perjury, that the following facts as stated in this document are true:

1)I am the natural parent or legal guardian of:

(Print Name of Minor Child)

2)The Minor Child's date of birth is:
(Month)
(Day)
(Year)
3)The child's age is:.
4)I have the legal authority to give consent for this child's Tattoo.
5)I consent to the tattooing of my child as follows:

(description & location of Tattoo)

(Signature of Parent/Legal Guardian)

Sworn to, or affirmed, in person before me, thisday of, 20, by

(Print Name)

who is personally known to me, or, who produced satisfactory identification in the form of

Seal:

(Signature of Notary)

(Print Name of Notary)

DH 4146, 7/12

64E-28.009, F.A.C.