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Authentic Images Uttoos & Plercings Consent X arfn <br /> In accordance wfih tale city of I suAlolr ort111itntco on tattooing or pitirving, thu allproptate (Utes ort this <br /> lMins nut st be completed by the applicant . <br /> AL1, ANSWrHS �t1151' BKO LEGIBLE. <br /> consent to this Tattoo Piercing. (Check one) I Corl.ib' tit that i aut 18years of <br /> age or oltlet: I have shown my v;tlid 1 . l). and also acknowledge that Authentic lntages Tattoos and Picrellig <br /> Is not responsionsible (far the Cave of the Tattoo or plercing mice I hoer! 1011 the theility: I agive u1 keep the <br /> area clean and hirection lMe , I will use nortnal hygiene and follow afteivaro instructions to keep it de4it <br /> and inktolon five . 1 acknowledge that the Arti4t is using sterile efluiptnent to do Iha tulltln 01' plcrcin}1, <br /> Amwer thv I111lowi g I lealth History Ottexiitnms , YES or NO ? <br /> ARE. YOU PRI?GNAN`I"? <br /> JAUNDICE OR I IEPATITIS? <br /> ALLEGIES 'Tet LA'MV PIGhIENTSlI)YI�S . ^ AN'I' I1�O !) t [ S'?� <br /> SKIN DISEASE ()Ii SKIN CANCT: R ? <br /> DIABETES ? <br /> SKIN �; l? NSIVI`I 'Y TO SOAPS Oil DISINIFEC''IATNT�S? <br /> 1? PII , i; 11SY, si: l7. URES , 14AITIN(: , Olt NARCOLEPSY? _ - . . <br /> TAKIN( k 1 EDICN11ONS, 1114000 '1' l1INNERS ;j <br /> IIIS' I'OIIYOlr ('04% INIL,INICAIILF DISEASE? �— <br /> I IISTOItY OF I IF: ;IIOIII II14IA Olt BLEEDING DISORI) I? It <br /> CARDIAC VALVE DISE Sr <br /> ISO you require antibiotics before SurgetIr or dental procedures? <br /> History of Herpes Infection on procedure area? <br /> It Is normal to expected redness , tenderness and even some <br /> swelling in the procedure area ( s) <br /> Print first and last name: Date of Birth <br /> lPrim Adniss 51'RRC014 CITY STATE ZIP <br /> 1 CrRTI 1v1" 11INC"1111: AI10VF. S` 51'1; 1) INFORNIXI'1t )N IS 'i' 111.1V TO TI1t'. Bwrofir hit' <br /> KNOWL1: 1)GE . <br /> ._ CI ,l E\'i' S1G ;�°°ATU11i`. I ►.,� I I '. <br /> Uj <br /> PIERCING MINOR CONSENT w <br /> I .nn the nattim. 1 invent or Ieg,�tl gaixlhm ol': Y <br /> ( Ptitti tt:iota M' tulttnrl C_1 <br /> hlhtors data of irhth : _ . _ - <br /> hi Inww tine ; <br /> I 1111y s tale lep1 tittlhorit}' to give vonNetrt to file h(W ), pltvrittky ill fht+ Child, r <br /> local lolle <br /> CL <br /> LJ.I <br /> tiignrttinc of Ihtrent/Lewfl Gual llalt trody prercing Prohibits Anyone <br /> from performing cM offering to J <br /> ARTIST/PIERCER ONLY perroan a pietong upon arryone IL <br /> BIRTH CERTII�ICAUSS under ryte taurreisthe <br /> PAlIIII, N CARI) IAN I1) ; plercft Is perfom (bd to the <br /> CI I I I , 1 ) SCI 1001 . 11 ) ; proaence of a putt of <br /> gtwrdjanor Al liarcled unci <br /> noruriod by tim minw's parent <br /> or guo dson Dort, not apply to <br /> ontmoclp,tted rMrw % and doat <br /> not inOudep+ercesof the oar , <br /> NEEDLE(S) USED . <br /> LOT #: <br />