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Male
Female
White
Black
Hispanic
Asian/Pacific Islander
Other
Dont Know
Business Phone
Allergies
Phone #
Body Art Establishment
Lot
This is not an emergency reporting system
.
If your issue or concern involves an immediate risk to life or personal safety,
Call 9-1-1 immediately
.
Concerns are reviewed during {[CNAME]} regular business hours, Monday through Friday from 8:30 a.m. to 4:30 p.m.
All requests will be reviewed and addressed in accordance with {[CNAME]} policies and within the limits of available resources.
Address
*
Date/Time Procedure
Race
Did the victim’s health history list any of the following medical conditions?
Other
Date Incident Reported by Victim
Diabetes
Attach all that apply:
Parent or Legal Guardian’s Signed Consent for Procedure to be Performed (if the victim is a minor)
Client’s Application and Aftercare Instructions
Qual
Victim Information
Pictures/Documents
Body Art Establishment Name
Report a Body Art Infection/Injury
Gender
Artist Name
Describe how the bite happened or provide any additional details regarding the incident.
Name
Address of Body Art Establishment (where procedure was performed)
*
Home Phone
Victim Address
City, State, ZIP
Describe the Area where the Incident occured.
Name of Victim (Last, First, MI)
Reported By
Date of Birth
Block
Email
Medications
Skin Conditions
{[ADDR]}
{[CITY]}, {[STATE]} {[ZIP]}
{[APHONE]}
{[AWEBSITE]}
Is the victim a minor?
Business Phone #
Important Notice
Location
Confirmation:
Date Submitted:
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