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MEDICAL QUESTIONNAIRE <br /> Please check any conditions listed below that apply to you <br /> • Diabetes • Epilepsy • Blood Thinners • =ainting or Dizziness <br /> • Herpes Asthma •Tuberculosis • Cardiac Valve Disease Ec7-mia/Psori 3sis <br /> • Pregnant and/or Nursing •Allergic reactions to antibiot cs • Scarring/KEloidi ig <br /> • Allergic reactions to latex • Skin Conditions Please explain: <br /> • Other risk factors for bloodborne pathogen exposure PI ease explain: <br /> How long has it been since you've eaten? Hours, Minutes (best to eat within 48hours of getting tattooed) <br /> Do you have any allergies? vES NO If YES, vrhzt? <br /> Do you have Hemophilia or other bleeding cisorders? <br /> Do you have requirements for antibiotics pr or to surgery or dental procedures? <br /> Do you use any medications tha`might affect the healing of the tattoo you wish to receive? <br /> Do you have any other medical or skin conditions that may Effect the outcome of your procFdu-e? <br /> Is there any other information you feel you should provide to the tattooer before gettirg tatoced? <br /> THE FOLLOWING SECTION BELOW TO BE FILLED OUT BY THE ARTIST <br /> BRAND NEEDLE SIZE, LOT, EXPIRATION DATE <br /> CLIENT IDENTIFICATION <br /> r � <br /> L J <br />