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THE 1 <br /> 2714 Country Club Blvd suite F, Stockton, CA 95204 <br /> MEDICAL HISTORY QUESTIONNAIRE <br /> Name: <br /> Last First <br /> Middle <br /> Date of Birth: <br /> Address: <br /> Emergency Contact: Phone( <br /> Do you have any of the following conditions: <br /> Yes/No <br /> —/—Diabetes <br /> ,!_Hemophilia or bleeding disorder <br /> _/_Allergic reactions to latex. <br /> _/Allergic reactions to antibiotics <br /> _f_History of heart valve disease <br /> History of Herpes infection at the procedure site <br /> Any risk factors for blood borne pathogens <br /> ___/_Scarring/Keloiding <br /> Skin conditions <br /> Do you have any allergies? If so, please list below: <br /> Do you use any medications that might affect the healing of the tattoo you wish to receive? <br /> Have you ever been prescribed antibiotics prior to dental or surgical procedures? <br /> Is there any other information that you feel you should provide to the body art practitioner? <br /> The information I have provided it complete and true to the best of my knowledge. <br /> Signature: Date <br /> "Needle Model# Lot# Tube Model# Lot# <br /> Liner Liner <br /> Shader Shader <br />