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If I suffer from hepatitis, or other risk factors for bloodborne pathogen exposure, or <br /> any other communicable disease, I have informed the Technician of the fact and have been <br /> advised of any medications and procedures necessary to promote the satisfaction healing of my <br /> tattoo. <br /> I do not suffer from any medical or skin condition(s) such as, but not limited to: <br /> keloid or hypertrophic scarring, psoriasis at the site of the permanent make-up, or any open <br /> wounds or lesions at the site of the tattoo. <br /> I do not have a history of medication use or currently using medication, including <br /> being prescribed antibiotics prior to dentafor surgical procedures. If I am on any medication for <br /> depression or any other mood-altering prescription, I will advise my Technician. <br /> PLEASE COMPLETE BOTH THE FRONT AND BACK SIDE OF THIS CONSENT FORM. <br /> I agree to reimburse each of the technician and the Body Art Facility for any <br /> attorney fees and costs incurred in any legal action I bring against either the Technician or the <br /> Body Art Facility and in which either the Technician or the Body Art Facility is the prevailing <br /> party. I agree that the courts of California State, in San Joaquin County, shat have personal <br /> jurisdiction and venue over me and shall have exclusive jurisdiction for the pirpose of litigating <br /> any dispute arising out of or related to this agreement. <br /> I certify that I have initiated the above paragraphs and have explained to my <br /> understanding this consent and the procedure process and what to expect following the <br /> procedure. I accept full responsibility for the decision to have this cosmetic tattoo work done. <br /> CLIENT <br /> SIGNATURE: <br /> DATE: <br /> TECHNICIAN: <br /> DATE: <br /> Technician Information only: <br /> EQUIPMENT <br /> USED: <br /> PIGMENTS <br /> PAGE 3OF3 <br />