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Name: <br /> Last First Middle <br /> Date Of Bbctk Sax: <br /> Address: <br /> Enmxenay Caltaet: Pte:U <br /> PAMW cibidt dWY COMAMMS wteesd 6e4rw AM drp&N rec <br /> ALLERGIC TO ANTIBIOTICS Exan"sY HERPES <br /> ALLERGIC TO LATEX FAINTING OR DIZZINESS HIV <br /> ASTHMA GOtV IS MRSAISTAPH R FECTION <br /> BLOOD THINNERS HEART C YNDMON PREGNANT/NURSING <br /> DIABETES HEMOPHILIA SCARIUM400TEELOmING <br /> ECZEMAMBORIASIS HEPATITIS SKIN COtdDITIONB <br /> OTHER"' <br /> *If yott dlecked odw,yl=n dw ft condition[. <br /> • I acknowledge that a tattoo is a permanent change to my appearance and that no representations have <br /> been made to me as to the ability to later change or remove my tattoo.To my knowledge, I do not have any <br /> Physical, mental or medical impairment or disability which might affect my well being as a direct or indirect <br /> result of my decision to have a tattoo. <br /> • 1 realize that variations in color and design may exist between any tattoo as selected by me and as ultimately <br /> applied to my body. I understand that if my skin color is dark oh,the colors will not appear as bright as they <br /> do on light skin. <br /> • Visual changes tattoo has given me instructions on the care of my tattoo while it's healing. I understand and <br /> we'll follow them. I had no knowledge that it is possible that the tattoo can become infected, particularly if <br /> you don't follow the instructions given. If any touch-up work to the tattoo is needed due to my own <br /> negligence, I agree that the work will be done at my own expense. <br /> • Visual changes Tattoo Studio has given me the full opportunity to ask any questions about the procedure <br /> and application of my tattoo and all of my questions, if any, have been answered to my satisfaction. <br /> • 1 acknowledge that I am not pregnant <br /> • 1 understand that inks are not FDA-approved and health consequences are unknown. <br /> 1 have read this release form and confirm that all the information I have given is correct. I <br /> understand that this is a release form and I agree to be legally Bound by it <br /> r Cw wjw eels r.m ower reww aapa gree oiewen <br /> Your Hama Tek""ree( ) <br /> Address c7ty State Zlp <br /> S69(w ure todays Dole <br />