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Client Record-Permanent Make-UD and Tattoolruz Informed Consent <br /> Last Name: First Name : <br /> Address: city: State Zip <br /> -chent Ua ot B-flftff Location on Way Name of 13o Artist <br /> COPY OR DESCRIPTION OF PERMANENT MAKE-UP OR TATTOO <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 Herpes Scarring/Keloiding Eczema/Psoriasis <br /> Heart Jon 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 art 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 Artist? <br /> 65 <br />