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Environmental Health - Public
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4100 – Safe Body Art
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PR0537807
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COMPLIANCE INFO
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Entry Properties
Last modified
5/5/2023 3:27:56 PM
Creation date
3/30/2023 1:03:06 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4100 – Safe Body Art
File Section
COMPLIANCE INFO
RECORD_ID
PR0537807
PE
4120
FACILITY_ID
FA0021685
FACILITY_NAME
TELEIOS TATTOO STUDIO (HIRSCHLER, DANIEL M)
STREET_NUMBER
21
Direction
S
STREET_NAME
SACRAMENTO
STREET_TYPE
ST
City
LODI
Zip
95240
CURRENT_STATUS
02
SITE_LOCATION
21 S SACRAMENTO ST
QC Status
Approved
Scanner
SJGOV\cfield
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EHD - Public
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zvo-rul M -11n, <br />In consideration of receiving body art from Daniel Hirschler, the practitioner at Teteios Tattoo, <br />(together with its employees, apprentices, and agents, the "Body Art Business") <br />1, confirm the following byinitiating each applicable item: <br />I 1PITZ4 111;V4 I &I I V14 I ITA 9 111 V4 I M 19 �4 It Cr I va 11 SM 11 Lot q Lei I t -M tu Eq I V_A a I Kellizo t I I va in 111 ff, I blefflim <br />speccations. <br />I understand that tattooing is permanent and that if I choose to have it removed, it may be <br />expensive and leave scars. <br />I am not under the influence of alcohol or drugs and that I am voluntarily submitting to <br />tattooed without duress or coercion. I <br />I agree to follow all instructions concerning the care of my tattoo, and that any touch-ups <br />needed due to my own negligence will be done at my own expense. <br />I understand there is a chance I might feet lightheaded, dizzy and/or faint during or after <br />being tattooed. <br />I agree to immediately notify the artist in the event I feet lightheaded, dizzy and/or faint <br />before, during or after the procedure. <br />1, -have been fully informed or the risks of tattooing including <br />but not limited to infection, scarring, difficulties in detecting melanoma, and allergic reactions to <br />tattoo pigment, latex gloves, and antibiotics. Having been informed of the potential risks associated <br />with getting a tattoo, I still wish to proceed with tattoo application and I assume any and all risks <br />that may arise from tattooing. <br />Signed Da te <br />
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