Laserfiche WebLink
MEDICAL HISTORY <br /> Please check any conditions listed below that apply to you. <br /> Diabetes Hemophilia T.B. Asthma <br /> Epilepsy Blood Eczema I Allergic reactions to <br /> Thinners Psoriasis latex <br /> Fainting or Herpes (location Scarring i Allergic reactions to <br /> Dizziness of permanent ink) Keloiding antibiotics <br /> Heart Condition Pregnant/ Skin Other: <br /> 1 1 Nursing I I Conditions <br /> Do you have a Cardiac Valve Disease? <br /> How long has been since you last ate? <br /> Do you have any allergies? <br /> Do you use any medications that might affect the healing of the body art you wish to <br /> receive? <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 /> Is there any other information you feel that you should provide to the body art <br /> practitioner? <br /> Permanent Cosmetics and Tattooing Page 2 of 3 <br />