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*Please Check ALL that A 0 <br /> Diabetes: BIood Thinning Medication: <br /> E ile s . Pre an Nursin : <br /> Hemophilia: Skin <br /> Condition Scarrin Keloidin : <br /> Heart Condition/Cardiac Fainting/Dizziness: <br /> Valve Disease: <br /> Anemia: He es: <br /> Allergic reactim to Other: <br /> Latex,Metals,Or <br /> Antibiotics: <br /> **Do you have any other medical or skin conditions that may interfere with the healing procedure? <br /> **Have you received an organ or bone marrow transplant?If so have you taken the prescribed preventative regimen of <br /> antibiotics required in advance of any invasive procedure such as piercing? <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 /> Are you currently on any medications?If so please list here. <br /> Is there any other information you feel you should provide to the body art practitioner? <br /> The information I have provided on this form is complete and true to the best of my knowledge. <br /> I HAVE READ THIS AGREEMENT,I UNDERSTAND IT,I AGREE TO BE BOUND BY IT. <br /> PRINT FULL NAME: D.O.B. <br /> ADDRESS: TELEPHONE: <br /> EMAIL: <br /> Signature of Participant: Date: <br /> Emergency Contact: <br /> SIGNATURE OF PARENT OR GUARDIAN IF PARTICIPANT IS A MINOR, <br /> And by their signature they,on my behalf,release all claims that both they and I have. <br /> Signature: Date: <br /> STAFF BELOW THIS LINE: <br /> PRICE: TIP: LOCATION OF PIERCING: <br /> MANTECA <br />