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Skin & Shades Studio <br /> Medical Questionnaire & Consent Form <br /> Thank you for trusting Skin & Shades Studio with your cosmetic tattooing services. <br /> Please fill out & return this health disclosure and service waiver before your <br /> appointment. <br /> First <br /> Name <br /> Last Name Date of <br /> birth <br /> Address <br /> City State Zip <br /> code <br /> Email Phone <br /> Valid ID Acknowledgement <br /> I understand that I am required to present a valid US government-issued ID at the time <br /> of my procedure <br /> El Driver's License <br /> ❑Passport <br /> Which tattoo procedure are you having done today? <br /> ❑Stretch mark camouflage tattoo <br /> ❑Scar camouflage tattoo <br /> El Dark scar neutralization <br /> ❑Scar revision with ink and serum <br /> ❑3D areola restoration <br /> ❑BB glow micropigmentation <br /> If other, please list here: <br /> How did you hear about Skin & <br /> Shades? <br /> CONFIDENTIAL MEDICAL HISTORY: <br />