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Tattooing <br /> I hereby request the Tattooing service ff IZO &8QW and <br /> agree to the following in accordance with regulations set up by the San <br /> Joaquin Environmental Health Department. <br /> 1. 1 am 18 years of age or older? - (a) Y/ <br /> 2. 1 am not under the influence of alcohol or drugs? Y / <br /> . Are you currently pregnant? - O1 Y / <br /> . 1 will disclose past and present exposure to and/or presence o : <br /> A) Hep.a 8) Hep.b C)He .c ) e .e h)Tetanus ) HIV/AIDS <br /> (Circle/Initial) <br /> If this does not apply , check here <br /> S. Do you currently have HIV/Al ? <br /> 6. Do you currently have weeping lesions, weeping dermatitis, are in a <br /> communicable stage of an infectious/contagious disease or have a <br /> parasitic infestation? Y / <br /> 7. 1 will disclose any infections of ever gettingherpes-119303 ( )2 <br /> . 1 will disclose any/all allergies tntial allergies as follows <br /> . 1 will disclose all history of diabetes-119303 O2 <br /> 1 . Are you allergic to latex gloves? -119303 ( )2 Y / <br /> 11. Are you allergic to antibiotics? -119303 ( ) / <br />