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Colorful Addictions Tattoo <br />24 E. I Oth st <br />Tracy CA 95376 <br />209434-5322 <br />Print name D.O.B. Age <br />Phone # <br />Address City <br />State Zip <br />Driver's license or I.D. # <br />E-mail Address <br />Emergency Contact: Print name Phone # <br />Are you over 18? YES NO <br />Have you ever been tattooed before? YES NO <br />Have ever been pierced before? YES NO <br />Are you pregnant? YES NO <br />1. Do you have a heart condition, epilepsy, or diabetes? YES NO If yes, please <br />explain <br />2. Are you a hemophiliac (bleeder) or on any medications that may cause bleeding or may <br />hinder blood clotting or any other bleeding disorders? YES NO <br />If yes, please explain <br />3. Do you have any communicable diseases or other risk factors for bloodborne <br />pathogens? (H.I.V A.ID.S., HEPITITIS) YES NO Please be honest <br />If yes, please explain <br />4. Are you under the influence of alcohol or drugs, prescribed or otherwise? YES NO <br />Please be honest <br />If yes, please explain <br />5. Do you have a history of herpes infection at the desired tattoo location? YES NO <br />Please be honest If yes, please explain <br />6. Do you have a history of cardiac valve disease? YES NO Please be honest <br />If yes, please explain <br />7. Are you currently on any medication? YES NO Please be honest <br />If yes, please explain <br />8. Do you currently require antibiotics prior to surgery or dental procedures? YES <br />NO Please be honest <br />9.Do you have any allergies? (Medicines, antibiotics, topical solutions or latex) YES <br />NO If yes, please explain <br />10. Do you have any medical or skin conditions that may affect the outcome of your <br />tattoo? <br />11. Is there any other information you feel you should provide the body art practitioner? <br />