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Clients Birthdate <br /> 1981-01-08 <br /> Street Address: <br /> Hh <br /> City: <br /> Hh <br /> State and Zip Code <br /> Test <br /> Phone Number: <br /> Test <br /> Emergency Contact (Name) <br /> Test <br /> Emergency Contact (Phone Number) <br /> Test <br /> Tattoo Information - Spelling of any words to be tattooed. <br /> Test <br /> Tattoo Information - Location of tattoo on BODY <br /> Test <br /> All questions about the body art procedure have been answered to my satisfaction, <br /> and 1 have been given written aftercare inctriirtionc for the nrnrer♦tare 1 am ahniit- <br /> to receive. <br /> Test <br />