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Are you currently undergoing any medical treatments or therapies? F-1 Yes ❑ No <br /> Do you or have you ever had or been treated for herpes/HIV or any other <br /> blood borne illnesses? R Yes ❑ No <br /> Ifyes,please specify: ........................................................... .............................................................................................................................................................................. <br /> Do you have a history of Herpes at the desired Procedure site? El Yes ❑ No <br /> Do you have any allergies?(latex,ointments OR Antibiotic medications) El Yes ❑ No <br /> Ifyes,please specify: .................................................................................................................................................................................................................................................................... <br /> Are you taking any medications? El Yes El No <br /> Ifyes,please provide details: ......................................................................................................................................................................................................................................... <br /> Are you diabetic? F] Yes El No <br /> Do you have any medical conditions that the artist should be aware op. El Yes El No <br /> Ifyes,please specify: .................................................................................................................................................................................................................................................................... <br /> Are you pregnant? [] Yes El No <br /> Have you ever experienced bleeding or bruising after medical procedures? El Yes El No <br /> Do you have a history of Hemophilia or other bleeding disorders? <br /> Do you or ANY ONE in your immediate family(mother/father/gra-lidparents)have F-1 Yes F-1 No <br /> a history of keloid or hypertrophic scarring? n Yes F] No <br /> Have you had any vaccinations or immunizations within the last month? <br /> Are you prone to fainting or dizziness? n Yes F1 No <br /> Do you have any history of seizures or epilepsy or cardiac valve disease? [] Yes El No <br /> Ifyes,please specify: .........................................I I I. I I -..................I.........................................I..... I I.......... ............................................... .............I....... <br /> Have you ever had a reaction to tattoo ink or experienced complications after a F] Yes ❑ No <br /> previous tattoo? <br /> Do you have other risk factors for El Yes ❑ No <br /> bloodborne pathogen exposure? <br /> Additional Details: <br /> I,the undersigned,confirm that I have provided accurate information about my medical history,medications, <br /> and previous treatments. <br /> ........... ...................... .................I...............I................... .................................I..........I.......... ................................................................................... <br /> Client's Signature: Date: <br /> THE CHAMELEON METHOD <br />