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Name: <br />crit <br />Consent Form <br />Artist: <br />First Last <br />Email: <br />DOB:Sex: Phone: ( )_ <br />Address: Emergency Contact: <br />Description of Tattoo/Procedure: <br />Please Check anv of the followine that cooly to you <br />Diabetes Cl Hemophilia OTB. ❑ Asthma ❑ Epilepsy L) Blood thinners Cl Eczema/Psoriasis ❑ Allergic <br />reactions to latex ❑ Fainting or Dizziness ❑ History of Herpes infection at the <br />procedure site ❑ Scarring/Keloiding ❑ Allergic reactions to antibiotics ❑ Cardiac valve disease❑ <br />Pregnant/Nursing ❑Skin Conditions ❑ Other: <br />List current medications, Mark N/A if none: <br />Y/N <br />❑❑ 1 am 18 years of age or older <br />❑❑ I understand that the process of tattooing involves the insertion of pigment into the skin's dermis. <br />O❑ 1 understand that after my tattoo is finished there will be a healing process including <br />peeling, itching, and discomfort. <br />❑❑ I understand that inks are not FDA approved and health consequences are unknown. <br />❑❑ 1 understand that a tattoo is fully permanent <br />❑ I have read and completed the consent form and was fully truthful to the best of my knowledge. <br />Client Signature: <br />Artist Signature: <br />