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In 2 Skin Tattoo — 2738 Pacific Ave., Stockton CA 95204 PRO537413 <br />June 17, 2021 <br />PHOTO 1: Client record indicates Stevie Vasquez practiced body art on 6/12/21 without a valid health permit. <br />Informed Co ort for Pontianent cosmvtica or Talk olnp <br />�LEASF REAo ANC INITIAL THE BOXEs WHEN YOU ARE cERTAIN vOU <br />UNpERSTAND THE IMPLICATIONS OF SIGNING <br />-' ro" –.:�. r race+.s,g a rascto rrot� __ " _ __ xnm preeu2rwr wt <br />+.: -z.,., w,m .— (sa9au+er v.m n emoMees. aPPenoces. W aa�a. uw'iaaao 8wuma� <br />bnosa�y a>: oroceoure hate oxen answered to rry xuatacaon. aria : ha.,o t>oe•+ <br />!Drthe rat[ao I am shout to Iecetwe <br />d=Kroad Or mown on .he cllont remro nom, ,s correctly arawn m <br />my soccincanane <br />I unaer5®nd that p(a oing is parmanaM and that it 1 choose to Tawe it rerm=v¢e, a nQY oe of Wert <br />and leave stirs. <br />l an" dine Person on The legal to presented as Proof that 1 am n Masi is Y"M of age. <br />_tam no[ urder Ne influence or alcohol or drugs and that I am voluntarily suWrnAing W <br />to be tabooed w pout duress or coer V ion <br />t understand Mere is a oosSibilay of an allergic reaction to the inks and pymerts cornmony <br />used in talo ping. <br />f urlderStand that Tattoo inks, s dyeand pigments have not been approved by Me federal Food arta <br />Drug Administration and that the health consequences of using these prooucts ace unknown. <br />— f understand there is a possibility of getting an infection, and 1 have been advksed of the signs <br />and symptoms of infection that indicate a need to seek meddal attention. <br />_ 1 agree to follow all instructions concerning the care of my tatioo. and that airy touch-up, <br />needed because of my own negligence will be done at my own ezpenre. <br />_ 1 understand that there is a chance I might feel lightheaded I duty during or atter being tstmailto <br />_ ! agree to immediately notify the practitioner In the event 1 feel Lightheaded. dizzy. andlor taint <br />before, during or after the procedure. <br />/• - � - - have been fully <br />inforTned of the risks of iadodlrtg <br />inGudrn but not limned to infection, scaning, d'ui cuiues in detectin melanoma.. and alter reactions to <br />tattoo Pigment latex gloves, and antibiotics. Having been informed of the potentia; risks assodaated'M�lh <br />getting a tattoo, I still wish to proceed with tattoo application and 1 assume any and all irks that tray aitse <br />from tattooing. <br />Sgned <br />Sandip Singh, REHS Page 1 of 5 <br />