Laserfiche WebLink
MEDICAL HISTORY <br /> PLEASE CIRCLE ANY CONDITIONS LISTED BELOW THAT APPLY TO YOU. <br /> TB EPILEPSY BLOOD THINNERS SCARRING/KELOIDING <br /> HIV ASTHMA ECZEMA/PSORIASIS GONORRHEA/ SYPHILIS <br /> OTHER HEPATITIS HEART CONDITION MRSA/STAPH INFECTIONS <br /> HERPES HEMOPHILIA PREGNANT/NURSIN ALLERGIC REACTIONS TO <br /> G LATEX <br /> DIABETES SKIN CONDITIONS FAINTING OR ALLERGIC REACTIONS TO <br /> DIZZINESS ANTIBIOTICS <br /> How long has it been since you last ate? <br /> Do you have any additional allergies such as metals, soaps, cosmetics or alcohol? <br /> Do you use any medications that might affect the healing of the body art you wish to receive? <br /> Do you have any other medical or skin conditions that affect the outcome of your procedure? <br /> Have you ever been prescribed antibiotics prior to dental or surgical procedures? <br /> Do you have any cardiac valve disease? <br /> Is there any information you feel you should provide to the body art practitioner? <br /> Katattoo docs\BodyArt SampleMedicalHistory-Tattoo.docSAMPLE FORM <br />