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If you answered YES to any of the above, Please explain. <br /> List of current medication(If applicable): <br /> Other risk factors for blood borne pathogens? <br /> ❑ No <br /> ❑ Yes,please explain: <br /> Do you have any other medical or skin conditions that may affect the outcome of your procedure? <br /> ❑ No <br /> ❑ Yes,please explain: <br /> Do you use any medications that might affect the healing of the body art you wish to receive? <br /> ❑ No <br /> ❑ Yes,please explain: <br /> Do you have any allergies? <br /> ❑ No <br /> ❑ Yes,please explain: <br /> How long has it been since you last ate?: <br /> Have you slept at least 6 hours last night or today?: YES[ ] NO[ 1: <br /> What part of the body are you getting tattooed?: <br /> Is there any other information you feel you should provide the tattoo artist?: <br /> NO[ ] YES[ ]: <br /> I DECLARE UNDER PERJURY THAT THE NAME ABOVE IS TRUE AND CORRECT. I HAVE <br /> READ AND UNDERSTOOD THE INFORMATIONABOVE. <br /> SIGNATURE DATE: <br /> FOR TATTOO ARTIST ONLY <br /> LINER/SHADER LOT LOT <br /> LINER/SHADER LOT LOT <br /> TATTOO ARTIST DATE: / / <br />