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Colorful Addictions Tattoo <br /> 450 ste. A E. 10th St <br /> Tracy CA 95376 <br /> 209- <br /> Print name D.O.B. Age <br /> Phone# <br /> Address City <br /> State Zip <br /> Driver's license or I.D. # <br /> E-mail Address <br /> Emergency Contact: Print name Phone <br /> NO ID = NO TATTOO <br /> Medical History <br /> • Are you over 18? YES NO <br /> • Have you ever been tattooed before? YES NO <br /> • Have ever been pierced before? YES NO <br /> • Are you pregnant? YES NO <br /> Do you have a heart condition, epilepsy, or diabetes? YES NO If yes, please <br /> explain <br /> Are you a hemophiliac (bleeder) or on any medications that may cause bleeding or may <br /> hinder blood clotting? YES NO <br /> If yes, please <br /> explain <br /> Do you have any communicable diseases? (H.I.V., A.I.D.S., HEPITITIS) YES NO <br /> Please be honest <br /> If yes, please <br /> explain <br /> Are you under the influence of alcohol or drugs, prescribed or otherwise? YES NO <br /> Please be honest <br /> If yes,please <br /> explain <br /> Do you have a history of herpes infection at the desired tattoo location? YES NO <br /> Please be honest <br /> If yes, please <br /> explain <br /> Do you have a history of cardiac valve disease? YES NO Please be honest <br /> If yes, please <br /> explain <br /> Are you currently on any medication? YES NO Please be honest <br /> If yes, please <br /> explain <br /> Do you currently require antibiotics prior to surgery or dental procedures? YES NO <br /> Please be honest <br /> Do you have any allergies? (Medicines, antibiotics,topical solutions or latex) YES <br /> NO If yes,please explain <br />