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Tattooing and Piercing Consent Form <br /> In accordance with the San Joaquin County on tattooing and piercing,the appropriate lines on <br /> this form must be completes by the applicant prior to the certify operator, Ly Nguyen,beginning <br /> any type of tattooing or body piercing in the facility of Fresher Nails. All answers must be <br /> legible. <br /> 1, consent to this tattooing or piercing (circle one that apply). I <br /> acknowledge that I am eighteen(18) years of age or older and have shown my valid I.D card. I <br /> also acknowledge that the above said business is not responsible for any mishap or injury <br /> occurring during or after that tattooing and piercing. I agree to keep the area clean and I must use <br /> normal hygiene and follow instructions to clean the area and keep it infection free. I <br /> acknowledge that the artist is using sterile equipment to do tattooing or piercing. <br /> Answer the following HEALTHY HISTORY questions YES or NO <br /> Do you have a history of: <br /> 1. Jaundice or Hepatitis? <br /> 2. Lymphadenopathy or lemphadenitis (swelling of the lymph nodes)? <br /> 3. Blood donation exclusion for other than hypertension and immediate illness? <br /> 4. Skin disease or skin cancer? <br /> 5. Allergies or anaphylactic reaction to needle injection? <br /> 6. Skin lesions or sensitivities to soaps, disinfectants, etc.? <br /> 7. Allergies or adverse reactions to pigments, dyes, or other skin sensitivities? <br /> 8. A history of diabetes? <br /> 9. Epilepsy, seizures, fainting, or narcolepsy? <br /> 10. Taking any medications, such as anticoagulants,which thin the blood and or interfere <br /> with blood clotting? <br /> 11. Communicable disease? <br /> 12. Are you generally in good health today? <br /> Print Name <br /> Address <br /> City State Zip Code <br /> Type of LD Date of Birth <br /> Signature Date <br /> Piercing to be performed(specify area) <br />