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RECEIVED CAENT TO TATTOO PROCEDURE <br /> DEMIAM —DATE <br /> DOB LICENSE NO. <br /> ENVIRONMENTAL HEALTH <br /> PERMI CITY <br /> STATE ZIP -HOME PH. WORK PH. <br /> I acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions <br /> which I might have about the obtaining of a tattoo and that all of my questions have been answered to my full <br /> satisfaction. I specifically acknowledge I have been advised of the facts and matters set forth below and I agree <br /> as follows: <br /> ® If I have any condition that might affect the healing of this tattoo, I will advise my tattooer. I am not <br /> pregnant or nursing. I am not under the influence of alcohol or drugs. <br /> ® 1 do not have medical or skin conditions such as but not limited to: acne, scarring (Keloid) eczema, <br /> psoriasis,freckles,moles,sunburn or herpies in the area to be tattooed that may interfere with said tattoo. If <br /> I have any type of infection or rash an <br /> re on my body,I will advise my tattooer. <br /> 0 Do you have any history of hemophilia or other bleeding disorder,Diabetes or any heart conditions such as <br /> cardiac valve disease if so please let the artist know nwv� t5 <br /> 0 1 have advised the tattooer of any allergies to metals,latex gloves, soaps and medications.I acknowledge it <br /> is not reasonably possible for the tattooer to determine whether I might have an allergic reaction to the <br /> piercing or processes involved in the tattoo and further acknowledge that such a reaction is possible. <br /> 0 1 acknowledge it is not reasonably possible for the representatives and employees of this tattoo shop to <br /> determine whether I might have an allergic reaction to the pigments or processes used in my tattoo, and I <br /> agree to accept the risk that such a reaction is possible. <br /> 0 1 acknowledge that infection is always possible as a result of the obtaining of a tattoo, particularly in the <br /> event that I do not take proper care of my tattoo. I have received aftercare instructions and I agree to follow <br /> them while my tattoo is healing. I agree that any touch-up work needed,due to my own negligence, will be <br /> done at my own expense. <br /> ® 1 realize that variations in color and design may exist between any tattoo as selected by me and as ultimately <br /> applied to my body. I understand that if my skin color is dark,the colors will not appear as bright as they do <br /> on light skin. <br /> 0 1 understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering <br /> procedures,it may result in adverse changes to my tattoo. <br /> 0 1 acknowledge that a tattoo is a permanent change to my appearance and that no representations have been <br /> made to me as to the ability to later change or remove my tattoo. To my knowledge, I do not have a <br /> physical,mental or medical impairment or disability which might affect my well being as a direct or indirect <br /> result of my decision to have a tattoo. <br /> 0 1 acknowledge I am over the age of eighteen and that I have truthfully represented to my tattooer that the <br /> obtaining of a tattoo is by my choice alone. I consent to the application of the tattoo and to any actions or <br /> conduct of the representatives and employees of the tattoo shop reasonably necessary to perform the tattoo <br /> procedure. <br /> CLIENT: DATE <br /> TATTOOER: DATE <br /> PLACMENT OF TATTOO —Description of Tattoo <br />