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Lucky You Tattoo <br /> 181 W.Alameda Manteca ca.(2o9)629-8321 <br /> Luckyyoutattoo@yahoo.com <br /> Name: Age: D.O.B Drivers Lic.# <br /> Address: Phone# <br /> Artist: Apt.date: Apt.time: Cost: Deposit: Placement of tattoo: <br /> Please answer the following,circle yes or no <br /> i.Have you ever been tattooed before? yes <br /> no <br /> 2.Are you 18 years of age or older? <br /> yes no <br /> 3.Are you hemophiliac?or have any other types of bleeding disorders yes no <br /> 4.Are you under ther influence of drugs/alcohol? yes <br /> no <br /> 5.Are you pregnant? <br /> yes no <br /> 6.Do you have epilepsy? <br /> yes no <br /> .Are you diabetic? <br /> yes no <br /> 8.Do you have HN/AIDS? <br /> yes no <br /> 9.1-lave you ever been diagnosed with hepatitis? yes <br /> no <br /> to.Have you have history of herpes on procedurs sight? yes no <br /> ii.Are you allergic to latex or other? <br /> yes no <br /> 12.Currently on any medication? <br /> yes no <br /> 13.have you ever been prescribed antibiotics prior to surgery or dental procedures yes no <br /> 14.Do you have a history of cardiac valve disease? yes no <br /> 15.Other risk factors for blood borne pathogens? yes <br /> no <br /> 16.Do you understand that this procedure may hurt more then other places? yes no <br /> 17.are you allergic to any antibiotics? Yes NO <br />