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Stockton Tattoo Co. Name: D.O. : I.D./D.L.Number: Phone Number: Address: City: State: Zip Code: I acknowledge by signing this agreement,that I have been given the full opportunity to ask any and all questions which I may have about obtaining a tattoo and that all questions have been answered to my full satisfaction. Are you 18 years of age or older? Are you hemophiliac or have any bleeding disorders? Are you under the influence of alcohol or drugs? Are you pregnant or nursing? Do you have epilepsy? Are you diabetic? Do you have IRV/AIDS? Have you been diagnosed with hepatitis A,B,or C? Do you have a history of herpes on or near the procedure site? Are you allergic to latex? — Do you have a history of he disease? — Do you have a history of cardiac valve disease? — Do you have requirements for antibiotics prior to surgery or dental procedures? — Are you on medication?If yes,please list: Do you have any risk factors for blood borne pathogens? If yes,please list: Please 'ttitial the folio g: I deretand that tattoos are permanent. I agree to follow all aftercare instructions given to me by my tattooer. I understand that certain skin types and complexions take color differently. I understand that there are NO REFUNDS ON TATTOOS. I understand that ink pigments are not FDA approved and health consequences are unknown. If I have a condition that might interfere with the tattoo procedure or affect the healing of the tattoo,I will advise my tattoo artist.I will also advise my tattooer of any allergies I may have and acknowledge that it is not reasonable possible for the tattooer to determine whether I may have an allergic reaction to the procedure or the pigments being used,but such reactions are always a risk.I acknowledge that infection is always possible in obtaining a tattoo, particularly in the event that I don't take proper care of my tattoo.Any touch ups due to my own negligence will be done at my own expense.By signing this document,I have read and understand all guidelines set forth above. Description of tattoo: Placement of tattoo: SIGNATURE: DATE: