COMPLIANCE INFO_HUGGINS, J - Laserfiche WebLink

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Colorful Addictions Tattoo 450 ste. A E. 101h st Tracy CA 95376 209- Print name D.O.B. Age Phone# Address City State Zip Driver's license or I.D.# E-mail Address Emergency Contact: Print name Phone# NO ID=NO TATTOO Medical History Have you ever been tattooed before? YES NO Have ever been pierced before? YES NO Are you pregnant? YES NO Do you have a heart condition,epilepsy,or diabetes? YES NO If yes,please explain Are you a hemophiliac(bleeder)or on any medications that may cause bleeding or may hinder blood clotting? YES NO If yes,please explain Do you have any communicable diseases?(H.I.V.,A.I.D.S.,HEPITITIS) YES NO Please be honest If yes,please explain Are you under the influence of alcohol or drugs,prescribed or otherwise? YES NO Please be honest If yes,please explain Do you have any allergies?(Medicines or topical solutions) YES NO If yes,please explain Do you have any medical or skin conditions that may affect the outcome of your tattoo? Is there any other information you feel you should provide the body art practitioner? Waiver and Release Int. 1.To my knowledge,I do not have any mental or medical impairment or disability which might affect my well being as a direct or indirect result of my decision to have any tattoo and/or piercing procedure done at this time. Int. 2. I agree to follow all instructions concerning the care of my tattoo and/or piercing while it's healing.I agree that any touch up work,due to my negligence,will be done at my own expense. Int. 3.I understand that if my skin color is dark,the colors will not appear as bright as they do on lighter skin. Additionally,I understand that the finished tattoo may vary somewhat in appearance,color and/or design from the paper or other drawing or photographic image which the tattoo design is based. Int. 4.All questions about the procedure have been answered to my satisfaction,and I have been given written aftercare instructions for the procedure I am about to receive. Int. 5.I am the person on the I.D.presented as proof I am at least 18 years of age. Int. 6.I have been advised that the tattoo will be permanent and that it can only be removed with a surgical procedure,and that any effective removal will leave permanent scarring and disfigurement.This cautionary notice is required to be provided to me by the health department and I hereby acknowledge receipt of this formal notice Int. 7.I understand there is a risk of an allergic reaction and agree not to hold Colorful Addictions responsible for any allergic reactions. Int. 8.I am not under the influence of drugs or alcohol and that I am voluntarily submitting to be tattooed without distress or coercion. Int. 9.I swear or affirm and agree that the above information is true and correct. I have been provided with information describing the tattoo and/or piercing procedure to be preformed and instructions on after care.I understand it is my responsibility to take care of my new tattoo and/or piercing site according to the instructions provided both verbally and in writing.I have been fully informed of the risks of tattooing including but not limited to infection,scarring,difficulties in detecting melanoma,and allergic reaction to tattoo pigments,latex gloves and antibiotics.Having been informed of all potential risks associated with getting a tattoo,I still wish to proceed with the tattoo procedure and I assume any and all risks that may arise from tattooing. Customer Signature Date DO NOT WRITE BELOW THIS LINE Tattoo Information Description of tattoo Exact spelling of names or words Location on body Price of tattoo Artists Name Artists Signature