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Do you wear contact lenses? o <br /> Do you have @ pacemaker? yes o <br /> Have you consumed drugs oralcohol inthe last 24hours?______yesnQ <br /> |nthe last 14days, did you undergo surgery when you were exposed toradiation Orhad any <br /> other medical interventios? yes_________nu <br /> How long has itbeen since you last ate? <br /> Doyou have any allergies such asmetals, soaps, cosmetics oralcohol? <br /> Are you onany medication(s)7 <br /> Do you have any medical or skin conditions that may affect the outcome of your procedure? <br /> Have you ever been prescribed antibiotics prior to dental or surgical procedures? <br /> Is there any other information you feel you should provide to the body art practitioner? <br /> The information I have provided is complete and true to the best of my knowledge. <br /> Signature ufClient: Date: <br /> Signature ofParent orLegal Guardian: Date: <br />