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Colorful Addictions Tattoo <br /> 1005 a Pescadero#215 <br /> Tracy CA 95376 <br /> 209-834-5322 <br /> Print name D.O.B. Age <br /> Phone# <br /> Address City <br /> State Zip <br /> Driver's license or I.D. # <br /> Parent/Gaurdian name <br /> Driver's license or I.D. # <br /> E-mail Address <br /> Emergency Contact: Print name Phone# <br /> NO ID=NO TATTOO <br /> Medical History <br /> • Are you over 18? YES NO Have you ever been tattooed before? YES NO <br /> • Have ever been pierced before? YES NO <br /> • Are you pregnant? YES NO <br /> 1. Do you have a heart condition, epilepsy, or diabetes? YES NO If yes, please <br /> explain <br /> 2.Are you a hemophiliac (bleeder) or on any medications that may cause bleeding or may <br /> hinder blood clotting or any other bleeding disorders? YES NO <br /> Ifyes,please explain <br /> 3. Do you have any communicable diseases or other risk factors for bloodborne <br /> pathogens? YES NO Please be honest <br /> Ifyes,please explain <br /> 4.Are you under the influence of alcohol or drugs,prescribed or otherwise? YES NO <br /> Please be honest <br /> Ifyes,please explain <br /> 5. Do you have a history of herpes infection at the desired location? YES NO Please <br /> be honest If yes,please explain <br /> 6. Do you have a history of cardiac valve disease? YES NO Please be honest <br /> Ifyes,please explain <br /> 7.Are you currently on any medication? YES NO Please be honest <br /> Ifyes,please explain <br /> 8. Do you currently require antibiotics prior to surgery or dental procedures? YES <br /> NO Please be honest <br /> 9.Do you have any allergies? (Medicines, antibiotics,topical solutions or latex) YES <br /> NO If yes,please explain <br /> 10. Do you have any medical or skin conditions that may affect the outcome of your <br /> procedure? <br /> 11. Is there any other information you feel you should provide the body art practitioner? <br />