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f T <br /> MEDICAL HISTORY, CONSENT AND RELEASE FORM <br /> ONE TIME TATTOO <br /> 1818 LUCERNE AVE. STOCKTON CA. 95203 <br /> 408-661-1295 <br /> Print Name D.O.B. Age Phone# Address <br /> City State Zip Driver's license or I.D.# <br /> NO D = NO TATTOO <br /> MEDICAL HISTORY <br /> Have you ever been tattooed before? YES NO <br /> Are you pregnant? YES NO <br /> Do you.have a heart condition,or,dtabetes? YES NO <br /> Any allergic reactions to latex and or to antibiotics? YES NO <br /> Any history of herpes infection on the procedure area? YES NO <br /> Are you a hemophiliac?Have a bleeding disorder?Or cardiac valve disease? YES NO <br /> Any current medications and or risk factors for blood borne pathogens? <br /> Any other requirements for antibiotics prior to surgery or dental procedures? <br /> Do you have any communicable diseases?(H.W.,A.I.D.S.,HEPITITIS) <br /> If yes,please explain <br /> I HAVE READ/ UNDERSTOOD AND AGREE TO THE FOLLOWING: <br /> 1. All questions have been answered to my satisfaction. <br /> 2. I agree the said tattoo is correctly drawn to my specification. <br /> 3. 1 understand that the said tattoo is permanent and that it can only be removed with a surgical procedure,and that any <br /> effective removal will leave permanent scarring. <br /> 4. This is to certify that I am at least 18 years of age. <br /> 5. I am not under the influence of alcohol or drugs and I am voluntarily submitting to be tattooed without dourness <br /> or coercion. <br /> 6. I understand that there is a possibility of an allergic reaction and or infection. <br /> 7. I agree that any touch up work,due to my negligence,will be done at my own expense. <br /> 8. I understand that the finished tattoo may vary somewhat in appearance,color and/or design from the paper or other <br /> drawing or photographic image,which the tattoo design is based. I also understand that over time,color and the clarity of <br /> the tattoo will fade due to unprotected exposure to the sun and the naturally occurring dispersion of pigment under the <br /> skin. <br /> 9. I agree to immediately notify the artist in the event I feel lightheaded,dizzy and/or faint before,during or after <br /> the procedure. <br /> 10.I understand that tattoo inks,dyes,and pigments have not been A approved and health consequences are unknown. <br /> 11.As consideration for being tattooed by this artist,I hereby agree for myself,my heirs,guardian,and legal <br /> representative not to sue One Time tattoo or its heirs or assigns in connection with any and all damages,claims, <br /> demands,rights and causes of action of whatever kind or nature based upon injuries or property damages to or <br /> death of myself or any other persons arising from my decisions to have any tattoo related work at this time, <br /> caused by any negligence of One time Tattoo employees.I hereby release both the artist and the shop from all <br /> actions,claims or demands. <br /> I agree that the above information is true and correct.I have been provided with information describing the <br /> tattoo procedure to be preformed and instructions on after care. <br /> Customer Signature Date <br /> DO NOT WRU'E BELOW THIS LIME <br /> Procedure description <br /> Did customer receive aftercare instructions(verbal&written)?YES NO <br /> Artist Lot/ID# <br />