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AUCYOUTATTOO,LL C 14051 Ca -88 Lockeford, 95240 NAME: D.O.Bt CELL: ADDRESS: CITY: ZIP: PLEASE READ: After your tattoo is completed, you will be provided with aftercare instrustionc. It is extremely important that you follow all instrustionc to ensure proper healing of your tattoo. Failure to follow all instructions may result in an infection or fading of your tattoo. Tattooing requires penetration of the skin to insert pigments permenantly.If you need medical treatment as a result of your participation in this procedure or any events incidental to this procedure, it will beat your own financial cost. PLEASE ANSWER THE FOLLOWING QUESTIONS: Are you 18 or older? Yes No Have you ever been tattooed before? _ Yes _ _ No Are you Hemophiliac or have any type of bleeding disorder? Yes _ _ No Are you under the influence of drugs or alcohol? Yes _ _ No Are you pregnant or nursing? Yes _ _ No Do you have epilepsy? Yes _ _ No Are you a diabetic? Yes _ No Do you have HIV/AIDS? _ Yes _ No Have you ever been diagnosed with hepatitis? _ Yes _ No Do you have a history of herpes on or near the procedure sight? _ Yes _ _ No Are you allergic to latex or anibiotics? Yes _ _ No Do you have a history of heart disease? Yes _ _ No Do you have a history of allergic reactions to latex? Yes _ _ No Do you have a history of cardiac valve disease? Yes _ _ No Do you have requirements for antibiotics prior to surgery or dental procedures? Yes _ _ No Are you on medication? If, yes please list: Do you have any risk factors for blood borne pathogens? yes No DISCRIPTION/ LOCATION OFYOUR TATTOO PLEASE INITIALTHE FOLLOWING: I understand that tattoos are permanent. I agree to follow all aftercare instructions given to me by my artist. I understand that certain skin tones take color differently. understand that the pigments are not FDA approved and health consequences are unknown. I underrstand that there are NO REFUNDS ON TATTOO NOR DEPOSITS. understand there can be some discomfort ,swelling or bruising following this procedure.. ASSUMPTION OF RISK, RELEASE OF LIABILITY, AND INDEMNIFICATION: 1, understand and have been fully informed of the risk associcated with receiving a permanent ink tattoo. I consent to receive a tattoo and assume any and all risks and agree to forever release, defend, indemnify and hold harmless, LUCKY YOU TATTOO LLC, and it's agents, employees, officers, directors, artist, contractors, members, heirs, or assigns ( hereinafter all referred to as LUCKYYOU TATTOO LLC), from any and all known, or unknown, past, present, or future, claims, demands, rights, liabilities, damages and causes of action, or the like arising under any theory or liability, (including breach of contract, tort, statutory, or regulatory violation), that may arise, involving or related in any way, to the tattoo that I will receive from LUCKY YOU TATTOO, LLC. ACKNOWLEDGE AND AGREED TO: Signature Artist: Date: Cost: consent for photography and videos ? yes_____ NO