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Tattoo <br /> Medical History FEB 2 7 20-13 <br /> Consent and Release Form <br /> PE9,',11713FRVC-,7--8 <br /> Please circle if you have any of the conditions below. <br /> **Diabetes** Heart Condition" Faintness/Dizzy Spells "Hemophilia **Asthma <br /> **Epilepsy **Eczema/Psoriasis "Infections **IB. "Scarring Keloiding "Herpes <br /> "Hepatitis(A)(B)(C) "Pregnant Nursing "Blood Thinning <br /> *Any history of allergic reactions to Latex? y N <br /> If Yes explain <br /> *Any history of Antibiotics y N <br /> if Yes explain <br /> *Any history of Hemophilia or any other Bleeding Disorders?Y y N <br /> if Yes explain <br /> *Any history of Cardiac Valve Disease y N <br /> if Yes explain <br /> *Any history of any other Blood Born Pathogens? y N <br /> if Yes explain <br /> Please list any known Allergies or Medications that you are currently taking: <br /> I hereby certify that to the best of my knowledge this information is correct. <br /> I've been given a chance to ask questions and they've been answered to my satisfaction. <br /> I am at least 18 years of age. <br /> I am not under the influence of alcohol or drugs. <br /> I understand there is a possibility of an allergic reaction. <br /> I understand there is a possibility of an infection. <br /> I understand that a tattoo is permanent. <br /> I agree to allow artist interpretation. <br /> I agree to follow all instructions given by"GYPSY LANTERN TATTOO PARLOR"and its employees <br /> concerning the aftercare of my tattoo. <br /> I understand that there is a chance I might feel lightheaded,dizzy and or faint due to my decision to <br /> receive a tattoo. <br /> **If you feel this way during or after the procedure,please let us know Immediately. <br /> I hereby release"GYPSY LANTERN TATTOO PARLOR" and its employees of all responsibility and liability <br /> for said tattoo(s). <br /> No refunds. <br />