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TATTOO MEDICAL HISTORY / LIABILITY CONSENT AND RELEASE FORM <br /> Please circle if you have any of the conditions listed below. <br /> Diabetes-Cardiac Valve Disease-Faintness or Dizzy Spells-Epilepsy-Hemophilia-Eczema/Psoriasis- <br /> Infections-T.B.-Scarring Keloiding-Herpes at procedure site-Asthma-Hepatitis-Pregnant Nursing- <br /> Blood Thinners. <br /> Please list any known allergies or medications that you are currently taking. <br /> Seek medical attention not limited to and including red line going from tattoo, bumps with puss, red <br /> and inflamed, swollen. <br /> I hereby certify that the best of my knowledge this information is correct. <br /> I have been given a chance to ask questions and were answered to my satisfaction. <br /> I am not under the influence of alcohol or drugs. <br /> I understand there is a possibility of an allergic reaction. <br /> I understand there is a possibility of infection. <br /> I understand that a tattoo is permanent. <br /> I agree to allow for artist interpretation. <br /> I agree to follow all instructions given to me by Art Body & Soul Tattoo Lounge and its employees <br /> concerning the aftercare of my tattoo. <br /> I understand there is a chance I may feel lightheaded, dizzy, and or faint due to my decision to <br /> receive a tattoo. <br /> IF you feel this way during or after the procedure, please et us know immediately. <br /> Post procedure instructions- 119303 (a)4 <br /> c) signs and symptoms of infection-elevated body temperature, red streaks going <br /> from procedure out toward heart. <br /> Circle YES or NO <br /> Y N ,History of allergic reaction to latex- 119303 (b) 2 <br /> Y N ,History of allergic reaction to antibiotics- 119303 (b) 2 <br /> Y N , History of hemophilia or other bleeding disorders 119303 (b) 2 <br /> Y N , History of cardiac valve disease- 119303 (b)2 <br />