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Name <br />Last First <br />Date of Birth Sex <br />Address <br />Emergency Contact <br />Phone L� <br />Please check any conditions listed below that apply to you <br />_ Diabetes <br />_ Hemophilia <br />_ T.B <br />_ Asthma <br />Epilepsy <br />_ Blood 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 allergies? <br />Do you use any medications that might affect the healing of the tattoo you wish to receive? <br />Do you have any other medical or skin conditions that may affect the outcome of your 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 />Is there any other information you feel you should provide to the body art practitioner? <br />Any other risk factors for blood borne pathogens? <br />The information I have provided on the document is complete and true to the best of my knowledge. <br />Signature of Client Date <br />