I, _________________________________, attest that I am the legal guardian of ___________________________________ who is currently __________ years of age and that I give him/her consent to have the following procedure(s):

_______________________________________________________________

_______________________________________________________________

I further attest that I have been informed of the possible risks involved with this procedure and of its permanence by the undersigned individual performing the procedure or by an employee or agent of the facility in which the procedure will be performed.

_______________________________________________________________
Signature of Guardian

_______________________________________________________________
Address

_______________________________________________________________
City, State, Zip Code

Date_______________________

___________________________
Signature of employee or Agent

___________________________
Date

As a minor, I assent to this procedure. Yes_______ No________

_____________________________________________ ______________
Signature of minor having body art procedure    Date

Author: Ronald Dawsey, Charlotte Denton

Statutory Authority: Code of Ala. 1975, §22-17A-7.

History: New Rule: Filed March 15, 2001; effective April 19, 2001; operative May 4, 2001. Repealed and New Rule: Filed December 20, 2006; effective January 24, 2007.