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OLIENT HISTORY FORM <br /> NAME: DATE OF BIRTH: <br /> ADDRESS: CITY: �� STATE: _ ZIP ..n <br /> CELL:(—)--- w EMAIL:,", <br /> MEDICAL QUESTIONNAIRE <br /> Because the following conditions may affect the rate of recovery of your procedure, please indicate if you currently have <br /> or ever have had any of the following: <br /> —Allergic reaction to latex _History of Herpes infection at the procedure site <br /> —Allergic reaction to antibiotics History of fainting or dizziness <br /> —Allergic reaction to pigments/dyes History of Epilepsy, Narcolepsy, or Seizures <br /> Asthma History of Eczema, Psoriasis, or other skin conditions <br /> Hemophilia or other bleeding disorders _History of cardiac valve disease <br /> Diabetes Required antibiotics prior to dental/surgery <br /> Tuberculosis procedures <br /> _Scarring/Keloid Other risk factors for blood borne pathogen <br /> HIV or other immune-system disease —Any medications, if so which medications <br /> Pregnant, Nursing/Breastfeeding <br /> INFORMED CONSENT TO BODY ART WORK <br /> In consideration of receiving BODY ART from , the body art Practitioner at Xochicalco <br /> Tattoos&Cosmetics. (together with its employees, apprentices of"Xochicalco Tattoos&Cosmetics") <br /> confirm the following by initialing each applicable item. <br /> Please Print Name <br /> All questions about the Body Art work have been answered to my satisfaction, and I have been given written and <br /> verbal aftercare instructions for the Body Art work I am about to receive. <br /> The Body Art has been described or shown to me and is correctly placed or drawn to my specifications. <br /> I understand that tattooing is permanent and that if I choose to have it removed, it may be expensive and leave <br /> scars. <br /> I am the person on the legal ID presented as proof that I am at least 18 years of age. <br /> I am not under the influence of alcohol or drugs and that I am voluntarily submitting to Body Art work without duress <br /> or coercion. <br /> Inks we use are not FDA approved and health consequences are still unknown. <br /> I understand there is a possibility of an allergic reaction. <br /> I understand there is a possibility of getting an infection. <br /> 1 agree to follow all instructions concerning the care of my Body Art work, and that any touch-ups or repairs that may <br /> become needed due to my own negligence will be done at my own expense. <br /> I understand that there is a chance I might feel lightheaded or dizzy during or after Body Art work. <br /> I agree to immediately notify the artist in the event I feel lightheaded, dizzy and/or faint before,during or after the <br /> procedure. <br /> I, In have been fully informed of the risks of Body Art including, But, not <br /> Please print name <br /> limited to infection, scarring, difficulties in detecting melanoma, and allergic reactions to pigments, latex gloves, and <br /> antibiotics. Having been informed of the potential risks associated with obtaining Body Art, I still wish to proceed with the <br /> Body Art work and I assume any and all risks that may arise from the Body Art work. If while in facility, I faint or get hurt <br /> the Body Art facility and its associates are not responsible. <br /> Signed Date <br /> TATTOO PLACEMENT, DESCRIPTION, AND PRICE <br /> NEEDLE INFO <br /> LOT NUMBER # EXP DATE: <br />