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Pure FormGallery & <br /> Tattoo <br /> Consent Form <br /> Name: Artist: _ <br /> First Last <br /> Email:_ <br /> DOB: _/ _/_ Sex: Phone: ( ) <br /> Address: _ Emergency Contact: <br /> Description of Tattoo/Procedure: <br /> Please Check any of the following that apply to you. <br /> Diabetes J Hemophilia JT.B. J Asthma J Epilepsy J Blood thinners J Eczema/Psoriasis J Allergic <br /> reactions to latex J Fainting or Dizziness J History of Herpes infection at the <br /> procedure site J Scarring/Keloiding ] Allergic reactions to antibiotics J Cardiac valve disease) <br /> Pregnant/Nursing JSkin Conditions J Other: <br /> List current medications, Mark N/A if none: <br /> History of hemophilia or any other blood disorders <br /> Requirements for antibiotics prior to surgery or dental procedures <br /> List any other risk factors for blood borne pathogens <br /> Y/N <br /> JJ I am 18 years of age or older <br /> JJ I understand that the process of tattooing involves the insertion of pigment into the skin's dermis. <br /> JJ I understand that after my tattoo is finished there will be a healing process including <br /> peeling, itching, and discomfort. <br /> JJ I understand that inks are not FDA approved and health consequences are unknown. <br /> JJ I understand that a tattoo is fully permanent <br /> J 1 have read and completed the consent form and was fully truthful to the best of my knowledge. <br /> Client Signature: ------------ - --- ---- , Date: ---� — -� -- - <br /> Artist Signature: _-----.---------_-__-- — Date: --�_—_/_-- <br /> For Shy use Only: <br /> Needles used: Lot#'s: <br /> Tubes used: Lot#'s: <br />