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<br />City <br /> <br />State- Zip <br /> <br />SS# <br /> <br />Artist <br /> <br />Design/procedure <br /> <br />Location of procedure <br /> <br />Answering yes to one or more of the above questions may suggest the need to consult a licensed physician as per <br />subparagraphs 5.1 and 5.2 of the Regulations for Body Art Establishments and Operators. <br /> <br />HEPATITIS B IMMUNIZATION RECORD <br /> <br />Name of Facility <br /> <br />Address <br /> <br />Name of Owner <br /> <br />Name of operator <br /> <br />Hire Date <br /> <br />Date of Birth <br /> <br />S/S# <br /> <br />Hepatitis B Immunization Record: <br /> <br />Date 1 st shot <br /> <br />Shot given by <br /> <br />Facility <br /> <br />Date 2nd shot <br /> <br />Shot given by <br /> <br />Facility <br /> <br />Date 3rd shot <br /> <br />Shot given by <br /> <br />Facility <br />