I, the undersigned, understand and agree to abide by the following in order to ensure that all records
and data pertaining to the client are kept confidential.
Furthermore, I understand that violation of this confidentiality statement is subject to appropriate
disciplinary action(s) on the part of the body art facility that could include being discharged from my
position and/or being subject to civil and possible criminal penalties brought against me. By
initialing the following statements, I further agree that:
Reports, records or information cannot be released except to appropriate authorities (state or
local health department officials, etc.).
Any document to be disposed of that contains patients identifiers shall be destroyed
to Section 12.5 of the “Requirements for Body Art Facilities.”
All confidential records shall be kept according to Section 12.2 of the “Requirements for
I will not receive visitors when confidential inf