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Date: <br />Last Name: <br />Medical Questionnaire and Tattoo Informed Consent <br />First Name: <br />Address: City: State: Zip <br />MEDICAL HISTORY <br />Please check any conditions listed below that apply to you <br />How long has it been since you last ate? <br />Do you have any allergies? <br />Do you use any mediation that might affect the healing of the body art you wish to <br />receive? <br />Do you have any other medical or skin conditions that may affect the outcome of your <br />procedure? <br />Have you ever been prescribed antibiotics prior to dental or surgical procedures? <br />Is there any other risk factors for blood borne pathogens you should provide to the <br />body artist? <br />COPY OR DESCRIPTION OF TATTOO <br />accept this body tattoo design and confirm the spelling <br />Signature: Date: <br />Diabetes <br />Hemophilia <br />T.B. <br />Asthma <br />Epilepsy <br />Fainting/ <br />Allergic reaction to <br />Allergic reaction to <br />Dizziness <br />metals/antibiotics <br />latex <br />Blood <br />Herpes <br />Scarring/Keloiding <br />Eczema/Psoriasis <br />Thinners <br />Heart <br />Pregnant/Nursing <br />Skin Conditions <br />Other: <br />Condition <br />How long has it been since you last ate? <br />Do you have any allergies? <br />Do you use any mediation that might affect the healing of the body art you wish to <br />receive? <br />Do you have any other medical or skin conditions that may affect the outcome of your <br />procedure? <br />Have you ever been prescribed antibiotics prior to dental or surgical procedures? <br />Is there any other risk factors for blood borne pathogens you should provide to the <br />body artist? <br />COPY OR DESCRIPTION OF TATTOO <br />accept this body tattoo design and confirm the spelling <br />Signature: Date: <br />