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Client Record - Permanent Malce-Up and Tattooing Informed Consent <br />Last Name <br />Address <br />First Name: <br />: City : <br />�State : Zip <br />tion m a e ooh oca on on or <br />��_ ame o oc y ris` <br />COPY OR DESCRIPTION OF PERMANENT MAKE-UP OR TATTOO <br />I accept this body tattoo. Client Signature Date <br />irI�✓t�riL fi13 1 UK <br />Please check any conditions listed below that apaiv to vou. <br />Diabetes Hemophilia <br />How long has <br />T.[3. <br />Asthma <br />Epliepsy <br />Fainting or <br />_ <br />Allergic reaction to <br />Allergic reactions to <br />Dizziness <br />any metals/ <br />latex <br />antibiotics <br />Blood Thinners <br />Herpes <br />Scarring/Keloiding <br />Eczema/Psoriasis <br />Heart Condition <br />Pregnant/Nursing <br />Skin Conditions.j <br />Other <br />it been since you last ate? <br />Do you have any allergies? <br />Do you use any medications that might affect the healing of tf�e body art you wish to receive? <br />Do you have any other medical or skin conditions that may affect the outcome of your procedure? <br />Have you ever been prescribed antibiotics prior to dental or surgical procedures? <br />Is there any other information you feel you should provide to the body artist? _ <br />