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Consent Form <br /> Name: Artist: <br /> First Last <br /> Email: <br /> DOB: f f Sex: Phone: ( j - <br /> Address: Emergency Contact: <br /> Description of Tattoo/Procedure: <br /> Please Check any of the following that apply to you. <br /> Diabetes ❑ Hemophilia ❑T.B. ❑ Asthma ❑ Epilepsy❑ Blood thinners ❑ 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 /> ❑❑ I 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 /> ❑❑ I 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 /> ❑❑ I 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: Date: <br /> Artist Signature: Date: <br /> For Shop use Only <br /> Needles used: Lot#'s: <br /> Tubes used: Lot#'s: <br />