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Lasta e First Name <br /> Address <br /> Street Apt. # city State ZIP <br /> Client Date of Birth Name of Piercing &Location on Name of Body Plercer <br /> Body <br /> I accept this body piercing. Mien: Signature Date <br /> ID ilk <br /> r <br /> I <br /> a <br /> EDICAL,HISTOI $ <br /> Please deck any conditions listed below that apply to you. <br /> [ <br /> Diabetes Hemophilia T.B I Asthma <br /> Epilepsy f Blood Thinners Eczema/Psoriasis Allergic reactions to latex ,.. <br /> Painting or Herpes Scarring/Keloiding Allergic reaction to antibiotics <br /> Dizziness I Allergic reaction to any meM sj <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 ai€ect 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 in€ormation you feel you should provide to the body piercer? <br /> Body Piercing Page 1 of 2 <br />