Laserfiche WebLink
e k <br /> w <br /> f ' <br /> MedicalOURS rA <br /> gursuant.to Hea thy ando <br /> m <br /> The questionnaire and all shall be considered confidential information.The body art facility <br /> shall maintain the privacy of all the information and shall not sell,share or transfer any information. <br /> Please initial that you ham mad the medicaland conditions <br /> I <br /> air❑ I. Are you is or War? <br /> ❑ 2.Are you a diabetic? .If,so please contact your <br /> physician before proceeding with your tattoo. <br /> ❑ 3 in ? <br /> ❑ 4.Are you a! e" ? s.oo you have any i ? .If, <br /> so <br /> please contact your doctor before proceedmi;with any <br /> OIL- <br /> El 6. Are you under the hftence of any drugs or alcohol? <br /> ❑ ?, Are Vou taking anY PmwfWm ? if, <br /> more room Is needed please ask for another sheet of paper� g. Do you have any known <br /> el e ? Any of the tattoo Inks? - <br /> ❑ if,yes what kind of allefgIc reaction do you haw?- <br /> ❑ 9. nave you ever had herpes or any other skin Infections or disease in the area being worked on? <br /> .if,yes please contact your phVsWan before proceeding with your tattoo. <br /> ❑ i#,so please contact your physician before proceeding <br /> with r tattoo. <br /> ❑ i1.Any history of cardiac ? <br /> ❑ received an o if,Ves,.You will need to contact your physician <br /> before proceeding with your tattoo. <br /> Nk <br /> ❑ 12.Do have any requkenmft for antibiotics Prior to surgery Or any dentai <br /> procedure?_ . <br /> t° <br /> ❑ ? _ <br />