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0 release forms 2015 Lucky You Tattoo 181 w.Alameda Manteca ca. (209)629-8321 Luckyyoutattoo@yahoo.com Name: Age: D.O.B Drivers Lic. Address: Phone# Artist: Apt. date: Apt. time: Cost: Deposit: Placement of tattoo Please answer the following circle yes or no 1.Have you ever been tattooed before? yes no 2.Are you 18 years of age or older? yes no 3.Are you hemophiliac? yes no 4.Are you under ther influence of drugs/alcohol? yes no 5.Are you pregnant? yes no 6.Do you have epilepsy? yes no 7.Are you diabetic? yes no 9.Have you ever been diagnosed with hepatitis? yes no 10.Have you have history of herpes on proceders sight? yes no 11.Are you allergic to latex or other? yes no 12.Currently on any medication? yes no 13.do you have requierments to antobiotics or reactions yes no 14.Do you have a history of heart disease? yes no 15.other risk factors for blood borne pathogens? yes no 16.Description of procedure. . . . Tattoo or other 17.Do you understand that this procedure may hurt more then other places yes no I understand that tattoos are perminate. i agree to follow all instructions given to me regarding my tattoo. . iundertand that certain sypes of skin take color different. i understand there are No REFUNDS. -Tattooing requires penitrating the skin with a needle to insert perminate piments. I agree to release, forever the discharge, and hold harmless amd employee of Lucky You Tattoo. Claims, damages, or legal actions arising or affliated to any service performed at Lucky You Tattoo will not be responsible. if there is any sign of infection Lucky You Tattoo is NOT responsible for medical attention. -I have read and agree to all of the above and everything i have stated on this for is true and correct. signature: x Date: Page 1