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<br />If you answered YES to any of the above, Please explain. <br />___________________________________________________________________________________ <br />___________________________________________________________________________________ <br />List of current medication(If applicable): <br />___________________________________________________________________________________ <br />___________________________________________________________________________________ <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 /> <br />How long has it been since you last ate?:____________________________________________________ <br />Have you slept at least 6 hours last night or today?: YES[ ] NO[ ]:__________________________ <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 /> <br />I DECLARE UNDER PERJURY THAT THE NAME ABOVE IS TRUE AND CORRECT. I HAVE <br />READ AND UNDERSTOOD THE INFORMATION ABOVE. <br /> <br /> <br />SIGNATURE_________________________________________________DATE:_____/______/_____ <br /> <br /> <br />______________________________FOR TATTOO ARTIST ONLY_______________________________ <br /> <br />LINER/SHADER_______________________________________LOT________________LOT_____________ <br />LINER/SHADER_______________________________________LOT________________LOT_____________ <br /> <br />TATTOO ARTIST_________________________________________________DATE:_____/______/_____ <br /> <br />