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I CONSENT TO TATTOO PROCEDURE Date: Name: Address: city State Zip D.O.B. Phone: I acknowledge by signing this agreement that I have of en given the full tattoo and that all of unity t st ask any have d all questions which I might have about the obtaining health been answered to my full satisfaction. I also acknowledge that NO INK is FDA approved, consequences are unknown, TATTOOS ARE PERMANENT, and that variations in color and design may happen depending on my skin type and complexion. Placement Of Tattoo. Description Of Tattoo: Yes No Please check as applicable: I am 18 years of age or older: I am pregnant and/or nursing: — _ procedure site: I have a history of Herpes at/or around the — — I have a history of Diabetes: have a history of Latex allergies: I have a history of allergies to Antibiotics: Please List: disorders: — — I have a history of Hemophilia or other bleeding — I have a history of Cardiac Valve Disease or other heart diseases: — — have a history of AIDS/HIV: I have a history of Hepatitis A, B, or C: Please list any current medications: — I have been prescribed antibiotics prior to a dental or surgical procedure: Please List: Other risk factors for blood drugs and/or alcohol: borne pathogens: I am under the influence of � ion that may interfere with the tattoo procedure ooaasCs, freckles, Furthermore, t the if I have any condlt g eczema, ps sh on m body I will advise my Tattoo Artist. I will healing of the tattoo such as but not limited to; acne, scarring (keloid h g of infection or rash moles, sunburn, or ANY typesoaps, or medications and Tattooer of any allergies to any metals, latex, might have an also advise my possible for the tattooer to determine whether I acknowledge it is not reasonably p procedure or pigments used, but such reactiosare ays a rin the event allergic reaction to the pro possible in the obtaining of a tattoo,.particularly Iven to me, acknowledge that infection is always p agree to follow the aftercare nstructions9 ce will be m that I do not take proper care of my tattoo. I touch ups due to my own neg g process, and any thing is completed to the by my tattooer, during the healing p agree that every own expense. By signing this document, I a9 guidelines set forth above. done at my and that I have read and understand all g best of my knowledgepate: Client Signature: pate: Artist Signature: