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6 0 <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 /> S�tK M iCy4 L A T�aVTr ny, 2 b (� �,��t�«5�G�-�cs` -�-� t �c L� i�z P UZEb <br /> I hereby certify that to the best of my knowledge this information is correct. A N <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 Pet 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 Racked Wayz does not guarantee any tattoo below the shoe Idne. *(inh ar) <br /> Signature <br /> Name: <br /> Address: <br /> City State— <br /> Drivers <br /> tate Drivers License Number or I.D. <br /> D.O.B. Age Today's Date <br /> Guardian signature <br /> DO NOT WRITE BELOW THIS LINE <br /> TATTOO PIERCING <br /> ARTIST OR PIERCER <br /> PLACEMENT <br /> REMARKS PRICE <br />