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IMAI&DICAL - <br /> Please check any conditions_listed below that <br /> scare 1 Ll r bili TAsthma I <br /> .' �.._ _m Ca °ie E"(vi a N �'Zemal r i ns ' 11 -t G aa�..i a s to <br /> .� <br /> EP <br /> late <br /> Sit Tr�r 1 i crrr�glFCt�aiEr�g ,ll�rc�i � ti1 to <br /> Dizziness <br /> 1-leart Condition ; R p Other <br /> s <br /> c ;ycu haa�� a Cardiac Valve Disease <br /> How long bait been since you last ate <br /> Do you have any allergies? <br /> Do you use anytdi atone that might affect the healingf the body art you Irish to receive? <br /> Cao VOLT h8jva arty Gthe r m $c1 r skin c nWo6s that M8. ftp t 4L!-,G GUtCOM e Of YOUr pro ceduf,` <br /> Have you ever been p sscribed anfibiofics prior to dental or surgical prcceduresq? <br /> -there any other information you feel you should prolAde to the body art pr ctitic�=� r'? <br /> m <br /> Pem);Fmizzot Cos,Tf,,!i(ts and Taftooing Page 2 of <br />