Laserfiche WebLink
CLIENT RECORD: <br /> Diabetes: Hemophili <br /> Epilepsy: Her es: <br /> FaintinSIDizziness: Pre an Nursing: <br /> Heart Eczema/Psoriasis., <br /> Conditions/Cardiac <br /> Valve Disease. <br /> Scarring/KeloidinW. SIdn Conditions: <br /> Allergic Reaction to Allergic Reaction to <br /> Latex: Antibiotics: <br /> Other• <br /> How long since you last ate? <br /> Do you have any allergies? <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 art practitioner? <br /> Are you currently on any medications?If so please list here. <br /> The information I have provided on this form is complete and true to the best of my knowledge. <br /> PRINT FULL NAME: D.O.B. <br /> EMAIL: <br /> ADDRESS: TELEPHONE: <br /> EMERGENCY CONTACT: <br /> Signature• Date: <br /> ARTIST USE ONLY BELOW <br /> Needles: Tubes: Manufacturer: <br /> Quote/Estimate:-Tip$:-Deposit$: Total$: <br /> MANTECA <br />