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SECRET SIDEWALK TATTOO <br /> CONSENT FORM <br /> NAME DATE <br /> DOB LICENSE # <br /> ADDRESS CITY <br /> STATE ZIP CELLPHONE WORK# <br /> I acknowledge by signing this agreement that I have been given the full opportunity <br /> to ask any and all question which I might have about the obtaining of a tattoo and <br /> that all of my questions have been answered to my full satisfaction. <br /> • If I have any condition that might affect the healing of this tattoo, I will <br /> advise my tattoo artist. I am not pregnant or nursing. I am not under <br /> the influence of alcohol or drugs. <br /> ® I do not have medical or skin condition such as but not limited to: <br /> acne, scarring (Keloid) eczema, psoriasis, freckles, moles or sun burn <br /> in the area to be tattooed that may interfere with said tattoo. If I have <br /> any type of infection or rash anywhere on my body, I will advise my <br /> artist. <br /> • I acknowledge it is not reasonable possible for the representatives <br /> and employees of this tattoo shop to determine whether I might have <br /> an allergic reaction to the pigments or processes used in my tattoo, <br /> and I agree to accept the risk that such a reaction is possible. <br /> • I've been informed that currently the ink used in my tattoo is not FDA <br /> approved and health consequences are unknown. <br /> • I acknowledge that infection is always possible as a result of the <br /> obtaining of a tattoo, particularly in the event that I do not take proper <br /> care of my tattoo. I have received after care instructions and I agree to <br />