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Client Record - Body Piercing Informed Consent <br /> Last Name: First Name: <br /> Address: City: State:-Zip <br /> Client Date of Birth Name of Piercing&Location on Body Name of Body Piercer <br /> I accept this body piercing.Client Signature: Date: <br /> MEDICAL HISTORY <br /> Please check any conditions listed below that apply to you. <br /> Diabetes Hemophilia TB Asthma <br /> Epilepsy Fainting or Allergic reaction to Allergic reactions to <br /> Dizziness any metals/ latex <br /> antibiotics <br /> Blood Thinners I Herpes Scarring/Keloiding Eczema/Psoriasis <br /> Heart Condition Pregnant/Nursing Skin Conditions Other <br /> How long has it been since you last ate? <br /> Do you have any allergies? <br /> Do you use any medications that might affect the healing of the body piercing you wish to receive? <br /> Do you have any other 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 piercer? <br />