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V <br /> ~ TATTOO AND PIERCING MEDICAL HISTORY/ <br /> LIABILITY CONSENT AND RELEASE FORM <br /> Please circle if you have any of the conditions listed below. <br /> Diabetes-Heart Condition- Faintness or Dizzy Spells- Epilepsy-Hemophilia-Eczema/Psoriasis- <br /> Infections-T.B. - Scarring Keloiding- Herpes-Asthma- Hepatitus-Pregnant Nursing-Blood Thinners- <br /> Please list any known Allergies or Medications that you are currently taking. <br /> I hereby certify that to the best of my knowledge this information is correct. <br /> I've been given a chance to ask questions and they've been answered to my satisfaction. <br /> This is to certify that I am at least 18 years of age. <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 an 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 Wicked Wayz Tattoo and its employees concerning the aftercare of my tattoo or <br /> piercing. <br /> I understand that there is a chance I might feel lightheaded,dizzy and or faint due to my decision to receive a tattoo or piercing. <br /> If you feel this way during or after the procedure,please let us know immediately. <br /> Parents/Guardian signature of minor receiving body piercing—119302(b) <br /> Post procedure instructions—119303(a)4 <br /> c)signs and symptoms of infection— <br /> elevated body temperature,red streaks going from procedure out towards the heart. <br /> History of allergic reactions to latex—119303(b)2 <br /> History of allergic reactions to antibiotics—119303 (b)2 <br /> History of hemophilia or other bleeding disorders— 119303(b)2 <br /> History of cardiac valve disease—119303(b)2 <br /> Requirements for antibiotics prior to surgery or dental procedures—119303(b)3 <br /> Other risk factors for blood borne pathogens—119303(b)4 <br /> I hereby release Wicked Wayz Tattoo Inc.and it's employees of all responsibility and liability for said tattoo. <br /> No refunds. <br /> *I understand that Wicked Wayz does not guarantee any tattoo below the shoe line *(inidar) <br /> Signature <br /> Name: <br /> Address: <br /> City State Zip <br /> Drivers License Number or I.D. <br /> D.O.B. Age Today's Date <br /> Guardian signature <br /> ..................................................... ..................................... . <br /> ....................DO_NOT WRITE BELOW THIS LINE <br /> ... <br /> TATTOO PIERCING <br /> ARTIST OR PIERCER <br /> PLACEMENT <br /> REMARKS PRICE <br />