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FINAL DESTINATION CONSENT TO TATTOO <br /> NAM:-:: Date: DOB: <br /> Address: City: State: Zip Code: <br /> Phon Email: <br /> DESC3IPT 0-4: PLACEMENT: ARTIST <br /> I ACKI,W0V/_AGE BY SIGNING THIS AGREEMENTTHAT I HAVE BEEN GIVEN FULL OPPORTUNITY TO ASK ANY AND ALL <br /> QUES-ONS%uHICH I MIGHT HAVE OBTAINING OF A TATTOO AND THAT ALL OF MY QUESTIONS HAS BEEN ANSWERED-C MY <br /> FUILL 5AT6FA-­TION.I ALSO ACKNOWLEGDE-HAT NO INK IS FDA APPROVED HEALTH CONSEQUENCES ARE UNKNOWW, <br /> TATTOOS kR_PERMANENT AND THAT VARIATIONS IN COLOR AND DESIGN MAY HAPPEN DEPENDING ON MY SKIN TYPE AND <br /> COMFLD(+)1`_ <br /> PLEASE CF_:<AS APPLICABLE: NO YES <br /> I am L ye=_rs old or olcer <br /> I am pr--gra i-and/or nursing <br /> I am urdiertrw influence of drugs and/or alcohol <br /> I have a Wile~of diabetes <br /> I have E hi;;to-of latex allergies <br /> I have z hixo-of cardiac/heart diseases <br /> I have z hixo-r of AIDS,/HIV <br /> I have a hi;zo-of hepatitis A,B or C If yes,which one: <br /> I have z hi:=o-of hemophilia or other bleeding disorder: <br /> I am on blmx_hinner medication If yes,which medication(s) <br /> I have a hi-.:o-of cardiac/heart diseases If yes,which diagnosis(s): <br /> Other rsk�f3--=ors for blood borne pathogens <br /> Artists are no=CPR certified.In case of 911 emergencies,would you like to be performed CPR DNR <br /> FUTHERVK>E,1:1 HAVE ANY CONDITION THAT MAY INTERFERE WITH THE TATTOO PROCEDURE OR AFFECT THE HEALING OF THE TAT00 SUCH <br /> AS BUT NOT LMED TO:ACNE,KELOID,ECZEMA,PSORIASIS,FRECKLES,MOLES,SUNBURN,OR ANY TYPE OF INFECTION OR RASH ON MY BODY; <br /> I'LL AD'ACE rAr-ATTOO ARTIST.I WILL ADVICE MY ARTIST OF ANY ALLERGIES TO ANY METAL,LATEX,SOAP OR MEDICATION AND <br /> ACKNOWLE=E T IS NOT R=SPONISBLE FOR THE ARTIST TO DETERMINE THE REACTION RISKS.I ACKNOWLEDGE THAT INFECTION IS ALWCYS <br /> POSSIB._IN Tf OBTAINING OF A TATTOO,EVEN ON THE EVENT THAT I DO NOT TAKE PROPER CARE OF MY TATTOO.I AGREE TO FOILLOW TF•E <br /> AFtERCORE �BnUCTIONS GIVEN TOME BY MY TA"TOO ARTIST THAT ANY TOUCH UPS ARE DUE TO MY NEGLIGENCE WILL BE DONE AT vIY <br /> OWN E4P_M;:. 3Y SIGNING-HIS DOCUMENT,I AM AGREEING THAT EVERYTHING IS COMPLETED TO THE BEST OF MY KNOWLEDGE Ar-C I HAVE <br /> READ AND UINI CRSTAND ALL GUIDELINES SET FORTH ABOVE. <br /> CLIENTS 313WITURE: DATE: <br /> ARTISTS.31--W ITURE: DATE: <br />