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Medical Questionnaire (Check Yes or No) <br /> Are you 18 or oldeO Yes <br /> History of herpes infection? Yes U No U <br /> History of diabetes? Yes v No n <br /> Allergic reaction to latex? Yes U No U <br /> Allergic reaction to antibiotics? Yes n No (7) <br /> History of hemophilia/bleeding disorders? Yes n No n <br /> History of cardiac valve disease? Yes Q No n <br /> Current medications (list): <br /> Require antibiotics before surgery/dental work? Yes n No d <br /> Risk factors for blood-borne pathogens (IV drug use, hepatitis, HIV, etc.)? <br /> Yes nNon <br /> I have disclosed all relevant medical history and understand that withholding <br /> information may increase health risks. <br /> Client Initials: <br /> Photo/Iveaia t_onsenr <br /> Q I consent to photos/videos of my tattoo being taken and used for the artist's portfolio,advertising. or <br /> social media. <br /> n'I do not consent to photos/videos of my tattoo being taken or used for the artist's portfolio,advertising, <br /> or social media. <br />