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SR0086863
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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E
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88 (STATE ROUTE 88)
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14051
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4100 – Safe Body Art
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SR0086863
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Entry Properties
Last modified
11/20/2024 9:24:02 AM
Creation date
9/1/2023 9:47:39 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4100 – Safe Body Art
File Section
COMPLIANCE INFO
RECORD_ID
SR0086863
FACILITY_NAME
LUCKY YOU TATTOO LOCKEFORD
STREET_NUMBER
14051
Direction
E
STREET_NAME
STATE ROUTE 88
City
LOCKEFORD
Zip
95237
APN
01937032
ENTERED_DATE
6/20/2023 12:00:00 AM
SITE_LOCATION
14051 E HWY 88
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
Scanner
SJGOV\cfield
Tags
EHD - Public
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I acknowledge that there is a chance I might feel lightheaded, dizzy during or after being tattooed. I <br />agree to immediately notify the practitioner in the event that I feel lightheaded, dizzy and/or faint <br />before, during or after the procedure. <br />I agree to follow all instructions concerning the care of my tattoo, and any touch ups needed because <br />of my own negligence will be done at my own expense. <br />Do you have diabetes? Herpes? Hemophilia or Cardiac Valve disease? If yes, Please discuss with your <br />artist. <br />Are you taking any medications? Recent medication use or antibiotics. If yes, Please discuss with your <br />artist. <br />I have read, understand and agree to the information provided above regarding telehealth. <br />Client Name* <br />Fi rst <br />Client Signature * <br />X <br />draw type <br />Valid Photo 1.11) <br />Upload or drag files here. <br />Please take a photo of a valid ID <br />Last <br />Date <br />6/28/2023 <br />Consent for photography and videos <br />R Yes No <br />Artist Name contact phone number <br />
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