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THE PIRATES LOUNGE TATTOO PARLOR <br /> 2714 COUNTRY CLUB BLVD SUfTE F,STOCKTON, CA 95204+ <br /> CONSENT OF APPLICATION OF TATTOO AND RELEASE AND WAIVER OF ALL CLAIMS <br /> DATE:__J___J <br /> ,acknowledge by signing this document that I have been given full opportunity to ask any and all <br /> questions which I might have about obtaining of a tattoo. I specifically acknowledge that I have been advised of the facts and matters set <br /> iorth below, and I agree as follows <br /> — 1 acknowledge that all deposits are non refundable <br /> !1 acknowledge that 1 am at least 18 years of age. <br /> �I acknowledge that I am not pregnant or nursing. <br /> _I acknowledge that I am free from Jaundice,Hepatitis or other communicable diseases. <br /> _i acknowledge that I am not under the influence of drugs or alcohol and I am voluntarily submitting to be tattooed without duress or <br /> coercion. <br /> —( acknowledge receipt of written instructions adulsing me of proper care of the tattoo. <br /> —I acknowledge that the tattoo should be considered permanent:that it can only be removed by surgical procedure and that any effective <br /> removal may leave permanent scarring or disfigurement, <br /> acknowledge that it is not reasonable possible for the representatives of The Pirates Lounge Tattoo Studio,to determine whether] <br /> might have an allergic reaction to the dyes, pigments and/or processes used in the execution of the tattno and i agree to accept the risk that <br /> such a reaction is possible. <br /> ____I acknowledge that tattoo inks are not FDA approved and health consequences are unknown. <br /> !I acknowledge that with tattoos there is always a possibility of getting an intectlor. <br /> ____Your tattoo should heat in 2 weeks. Refer to provided aftercare sheet for proper care instructions. Expect redness and soreness for the <br /> first 1-4 days. <br /> —i agree to release and forever discharge and hold harmless The Pirates Lounge Tattoo Studio,and it's contractors,employees,agents <br /> and/or representatives from any and all claims,damages or legal actions arising from or connected in any way with the tattoo or the <br /> procedure and/or conduct used to appiy said tattoo. <br /> Are there are other risk factors for blood Borne pathogens <br /> NAME: DOB: ^_ _ <br /> ADDRESS. CITY STATE,21P: <br /> TELEPHOIIIE:( j TATTOO DESIGNS <br /> -Arron <br /> -OCATION: COST: ARTIST: <br /> aGNATURE: <br />