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SECRET SIDEWALK TATTOOS <br /> CONSENT FORM <br /> NAME: DATE�� <br /> DATE OF BIRTH: LICENSE # <br /> ADDRESS: CITY <br /> STATE ZIP PHONE NUMBER:( ) - <br /> I acknowledge by signing this agreement that I have been given <br /> the full opportunity to ask any questions which I might have about the <br /> obtaining of a tattoo and that all of my questions have been answered <br /> to my satisfaction. <br /> • If I have any condition that might affect the healing of this tattoo, I will advise my <br /> tattoo artist. I am not pregnant or nursing. I am not under the influence of <br /> alcohol or drugs. <br /> • I do not have medical or a skin condition such as but not limited to: acne, <br /> scarring(Keloid) eczema, psoriasis, freckles, moles or sunburn in the area to be <br /> tattooed that may interfere with said tattoo. If I have any type of infection or rash <br /> anywhere on my body, I will advise my artist. <br /> • I acknowledge it is not reasonably possible for the representatives and employees <br /> of this tattoo shop to determine whether I might have an allergic reaction to the <br /> pigments or processes used in my tattoo, and I agree to accept the risk that such a <br /> reaction is possible. <br /> • I've been informed that currently the ink used in my tattoo is not FDA approved <br /> and health consequences are unknown. <br /> • I acknowledge that infection is always possible as a result of the obtaining of a <br /> tattoo, particularly if I do not take proper care of my tattoo. I have received <br /> aftercare instructions and I agree to follow them while my tattoo is healing. I <br /> agree that any touch-up work needed, due to my negligence, will be done at my <br /> own expense. <br />