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4100 – Safe Body Art
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PR0548626
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COMPLIANCE INFO
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Entry Properties
Last modified
5/7/2026 2:42:03 PM
Creation date
4/3/2025 11:46:04 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4100 – Safe Body Art
File Section
COMPLIANCE INFO
RECORD_ID
PR0548626
PE
4120 - BODY ART FACILITY-SINGLE USE
FACILITY_ID
FA0026472
FACILITY_NAME
ADORN ME TATTOO (BOU, JENNIFER)
STREET_NUMBER
5759
STREET_NAME
PACIFIC
STREET_TYPE
AVE
City
STOCKTON
Zip
95207
CURRENT_STATUS
Active, billable
QC Status
Approved
Scanner
SJGOV\sballwahn
Supplemental fields
Site Address
5759 B145 PACIFIC AVE STOCKTON 95207
Suite #
B145
Tags
EHD - Public
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The Tattoo Studio has given me the full opportunity to ask any question about the procedure and application of my tattoo and all <br /> of my questions have been answered to my satisfaction. (PLEASE INITIAL) <br /> The Tattoo Studio has given me instructions on the care of my tattoo while it's healing. I understand and will follow them. I <br /> acknowledge that it is possible that the tattoo can become infected, particularly if I do not follow the instructions given to me. If <br /> any touch-up work to the tattoo is needed due to my own negligence, I agree that the work will be done at my own expense. <br /> (PLEASE INITIAL) <br /> I am not under the influence of alcohol or drugs,and I am voluntarily submitting to be tattooed by the Tattoo Studio without <br /> duress or coercion. (PLEASE INITIAL) <br /> I do not suffer from diabetes,epilepsy,hemophilia, heart condition(s),nor do I take blood thinning medication. I do not have any <br /> other medical or skin condition that may interfere with the procedure,application or healing of the tattoo. I am not the recipient of <br /> an organ or bone marrow transplant or, if 1 am, I have taken the prescribed preventative regimen of antibiotics that is required by <br /> my doctor in advance of any invasive procedure such as tattooing or piercing. I am not pregnant or nursing. I do not have a mental <br /> impairment that may affect my judgement in getting the tattoo. (PLEASE INITIAL) <br /> I do not have a condition needing immunosuppressants- Crohn's Disease, Lupus,some skin conditions. (PLEASE INITIAL) <br /> I am not allergic to lidocaine,and consent to the use of a lidocaine solution as a numbing agent during the application of my tattoo. <br /> If you are allergic to lidocaine or do not want it to be used, please inform your tattoo artist prior to beginning the procedure. <br /> (PLEASE INITIAL) <br /> The Tattoo Studio is not responsible for the meaning or spelling of the symbol or text that I have provide to them or chosen from <br /> the flash (design) sheets. (PLEASE INITIAL) <br /> Variations in color and design may exist between the tattoo art I have selected and the actual tattoo when it is applied to my body. <br /> I also understand that over time,the colors and the clarity of my tattoo will fade due to unprotected exposure to the sun and the <br /> naturally occurring dispersion of pigment under the skin. (PLEASE INITIAL <br /> https://torm.jotform.corn/23'145'1878214154 5/12/25, 2 10AM <br /> Page 2 of 9 <br />
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