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10.Do you have a history of herpes at the proposed procedure site? YES NO 11.Are you allergic to latex? YES NO 12.Are you currently on any medication? YES NO 13.Have you ever been prescribed antibiotics prior to surgery or dental procedures? YES NO 14.Do you have a history of cardiac valve disease? YES NO 15.Is there other risk factors for blood borne pathogens? YES NO If yes,please explain: 16.Do you understand that this procedure may hurt more than other places on your body? YES NO 17.Are you allergic to any antibiotics? YES NO Please initial and read the following: I acknowledge that tattooing is a permanent change to my appearance and no representations have been made to me as to the ability to later change,alter,or remove my tattoo. I acknowledge receipt of written instuctions advising me of proper care of my tattoo and recongnize the absolute necessity of following those written instuctions.All questions about the body art procedure have been answered to my satisfaction. I acknowledge that variations in color and design may exist between any tattoos as selected by me as ultimately applied to my body. I acknowledge that tattoo inks,dyes and piugment have not been approved by the Federal Food and Drug Administration and health consequences of using these products are unknown. I understand there are NO REFUNDS. -I agree to realese and forever discharge and forever hold harmless East Main Tattoo and its associates from any and all claims,damages,or legal actions arising from or connected in any way with my tattoo or the procedures and conduct used to apply my tattoo and any and all tattoos applied by East Main Tattoo and its associates in the future. -I have read and agree to all of the above and everything I stated on this form is true and correct.