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Ll <br />E <br />Name <br />Last First <br />Date of Birth Sex <br />Address <br />Emergency Contact Phone ( <br />-. M � 'i, w1: ,•'I i il"I I =Oo <br />Diabetes <br />Hemophilia <br />T. <br />Asthma <br />Epilepsy <br />to Thinners <br />Eczema/ Psoriasis <br />Allergic reaction to Latex <br />Fainting or Dizziness <br />Herpes <br />Scarring/ Keloiding <br />Allergies to Bees <br />Heart Condition/ including History of Cardiac Valve disease <br />HIV/ AIDS <br />Allergic reactions to Antibiotics <br />How long has it been since you last ate? <br />Do you have any other medical or skin conditions that may affect the outcome of your <br />procedure? <br />Have you ever been prescribed antibiotics prior to dental or surgical procedures? <br />History of medication use or current medications you are taking? <br />1 11 11 11 I'lill! <br />Any other risk factors for blood bome pathogens? <br />knowledge. <br />Signature of Client Date <br />