Laserfiche WebLink
MEDICAL QUESTIONNAIRE <br /> PLEASE CHECK ANY CONDITIONS THAT APPLY TO YOU <br /> dtNBETES - EPILEPSY - HEMOPHILIA • BLOOD THINNERS�- FAINTING OR DIZZINESS <br /> J1iFRPFR - ASTHMA - TUBERCULOSES IARDIAC VALVE DISEASE_• ECZEMAIPSORIASIS <br /> PREGNANT AND/OR NURSING Pd-I ERGIC REACTION TO ANTIBIOTICS - SCARRING/KELOIDING <br /> �� <br /> r <br /> ALiERGIC REACTION TO LATEX SKIN CONDITIONS PLEASE EXPLAIN: <br /> Ni-IER RISK FACTORS FOR BLOODBORNE PATHOGEN EXPOSURE PLEASE EXPLAIN: <br /> afar!LONG WAR IT RFFK AINCF YOU'VE EATEN? HOURS. MINUTES.(BEST TO EAT WITHIN 4HRS OF GETTING TATTOOED) <br /> )0 YOU HAVE ANY ALLERGIES? YES. NO. IF YES,WHAT? <br /> )O YOU USE ANY MEDICATIONS THAT MIGHT AFFECT THE HEALING OF THE TATTOO YOU WISH TO RECEIVE? <br /> )O YOU}±AVE ANY OTHER MEDICAL.,OR SKIN CONDITIONS THAT MAY AFFECT THE OUTCOME OF YOUR PROCEDURE? <br /> S THERE ANY OTHER INFORMATION YOU FEEL YOU SHOULD PROVIDE TO THE TATTOOER BEFORE GETTING TATTOOED? <br /> rHE FOLLOYViNG SECTION BEI..IDW IS TOO BE FiLLED OUT BY THE AR l iS 1 <br /> INK BRAND NEEDLE(S) SIZE, LOT # AND EXP. <br /> ETERNAL INK CHEYENNE <br /> FUSION T TECH <br /> ` DYNAMO LXX TAI IOU <br /> SOLID INK PAPA <br /> SLIVER BACK ENVY <br /> WAVERLY <br /> OLD GOLD <br /> ORS <br /> C - - - -- -DEN'TtRC-A-MON <br />