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MEDICAL QUESTIONNAIRE <br /> Please check any conditions listed below that apptyto you <br /> 'Diabete<_, '€pilcpsy_ •iitstorVofHemootiiliaOrotherbleeding diwMa— _ <br /> 'Rivad Thinners__ 'Fainting or Diczlaess -- *History oiHerpesin'ection at the procedure slte_ <br /> •Asthma _ •Tube•cu;osis_ 'CardiacValveDisease_ •Eczema) sar;asis _ <br /> 'Pregnant and/orNursinp 'Allergic reac:ionstoandt:lctics 'SwrripeAelotding. <br /> 'Allergic reacriors to latex^ `Sk n Condatons_Please explein- <br /> •Lliher risk factors for bloodborne pathogen exposure_Pkdse axplain: <br /> Have you ever been prescribed antibiol ca prior to dental orturglcal procedures? <br /> flow long has t Peen since you last ate? <br /> Do you have any allergies? <br /> List current mecicanom <br /> Do you nave any other medlcay or skin conditions that map affeci the outcome of yap r procedure? <br /> is there any other intorme on you'eel you s»ould prov;oe to the Oody-it,practilwer? <br /> THE FOLLOWING SECTION TO BE FILLED OUT BYTHE ARTIST <br /> BRAND NEEDLE EXPIRATION DATE <br /> tt.li90 1V fNTINCA'n(1 N <br /> I� <br /> f <br /> i <br /> i r <br />