BOB BITNER TATTOO
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Section I. Patron's information
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Indicates required field
Patron's Name (FIRST, MIDDLE, LAST) If person is under the age of eighteen (18) parent or legal guardian's name shall also be provided.
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First
Last
Patron's date of birth
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Month, day, year
Patron's residence phone number
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Patron's address ( STREET, CITY, STATE, ZIP CODE)
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Patron's Driver's license number/ If under the age of eighteen, Driver's License number of parent or legal guardian
.
Patron's Driver's License Number
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Parent or Legal Guardian's Driver's License Number
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Procedure(s) to be performed (check all that apply)
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Tattoo
Body Piercing (list part of body below)
Branding
If piercing procedure was selected, please list
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Section II. medical/ health assessment - questions to be answered by patron.
Are you currently or have you ever used medications that contain a controlled substance?
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Yes
No
Have you ever been diagnosed by a medical doctor as having contracted a communicable disease such as Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and/or other blood borne pathogens? If so, when?
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Yes
No
If yes to communicable disease diagnosis, please indicate type and date of diagnosis.
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Have you ever been diagnosed by a medical doctor as having allergies?
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Yes
No
Have you ever been diagnosed by a medical doctor as having a disease that could affect the healing process, including diabetes?
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Yes
No
Are you currently under the influence of any illegal substances?
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Yes
No
Are you currently under the influence of an alcoholic beverage?
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Yes
No
Have you been diagnosed with jaundice within the past twelve months?
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Yes
No
Are you currently using any medications that contain blood thinners?
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Yes
No
Are you currently using Amy medications that weaken the immune system that fights infections?
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Yes
No
Section III. to be completed by the patron
I, ** enter name below**
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acknowledges that I am aware certain medical conditions and treatments and/or medications used to treat medical conditions may be adversely impacted by the procedure(s) of tattooing and/or piercing and/or branding. Such medical conditions include but are not listed to, impaired kidney and/or liver function, diabetes, jaundice, medication containing blood thinners, and medications that weaken the immune system.
I further acknowledge that the tattoo and/or brand should be considered permanent; that said tattoo and/or brand can only be removed with surgical procedure; and that any effective removal may leave permanent scarring and disfigurement.
I have read this form and confirm that all information I have given is correct. I understand that is a consent from and I agree to be legally bound to it.
Agreement to section III.
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By checking this box I give my consent and agreement
Name/ Signature (Type name to render as signature)
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Submit
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Tattoo Contact Form
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