Business Phone
Allergies
Phone #
Body Art Establishment
Lot
This is not an emergency reporting system.
If your issue or concern involves an immediate risk to life or personal safety, Call 9-1-1 immediately.
Concerns are reviewed during {[CNAME]} regular business hours, Monday through Friday from 8:30 a.m. to 4:30 p.m.
All requests will be reviewed and addressed in accordance with {[CNAME]} policies and within the limits of available resources.
Address *
Date/Time Procedure
Race
Did the victim’s health history list any of the following medical conditions?
Other
Date Incident Reported by Victim
Diabetes
Attach all that apply:
  • Parent or Legal Guardian’s Signed Consent for Procedure to be Performed (if the victim is a minor)
  • Client’s Application and Aftercare Instructions
Qual
Victim Information
Pictures/Documents
Body Art Establishment Name
Report a Body Art Infection/Injury
Gender
Artist Name
Describe how the bite happened or provide any additional details regarding the incident.
Name
Address of Body Art Establishment (where procedure was performed) *
Home Phone
Victim Address
City, State, ZIP
Describe the Area where the Incident occured.
Name of Victim (Last, First, MI)
Reported By
Date of Birth
Block
Email
Medications
Skin Conditions
{[ADDR]}
{[CITY]}, {[STATE]} {[ZIP]}
{[APHONE]}
{[AWEBSITE]}
Is the victim a minor?
Business Phone #
Important Notice
Location