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THE PIRATES LOUNGE TATTOO PARLOR <br /> 2714 Country Club Blvd suite F,Stockton, CA 95204 <br /> MEDICAL HISTORY QUESTIONNAIRE <br /> Name: <br /> last First Middle <br /> Date of Birth:_,/ / <br /> Address. <br /> Emergency Contact: Phonel <br /> Do you have any of the following condition_. <br /> y8S/NO <br /> / Diabetes <br /> _ _,Hemoohilia or bleeding disorder <br /> Allerpac reactions to Latey <br /> —'d—Allergic reactions to antibiotics <br /> _History of heart valve disease <br /> _J_____History of Herpes intectinn at the orocedure ss;=. <br /> _/,Any risk factors for blood borne patnogen: <br /> _/Scarring/Keloiding <br /> —,`_Skin conditions <br /> Do you have any allergies? If so, olease list below <br /> )o 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 Modell! Lot# <br /> Liner Liner <br /> Snader Shader <br />