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UPTOWN INK MEDICAL QUESTIONNAIRE <br /> (Per Health and Safety Code 119303) <br /> In accordance with California State Laws on Body Art and Piercing, the appropriate lines on this form <br /> must be completed by the applicant prior to the practitioner beginning any type of tattooing or body <br /> piercing. ALL ANSWERS MUST BE LEGIBLE <br /> Client Medical Information (Circle YES or O) <br /> • Are you currently Pregnant? YES NO <br /> • Do you have a History of Herpes? YES NO <br /> • Do you have a History of Diabetes? YES NO <br /> • Do you have a History of allergic reactions to latex? YES NO <br /> • Do you have a History of allergic reactions to antibiotics? YES NO <br /> • Do you have a History of Hemophilia or other bleeding disorders? YES NO <br /> • Do you have a History of Cardiac Valve Disease? YES NO <br /> • Do you have a History of Medication use or are currently <br /> Using medication? (including prescribed antibiotics prior to <br /> Dental or surgical procedures)? YES NO <br /> • Do you have any RISK factors for Blood Borne Pathogens? YES NO <br /> • Do you have any allergies such as metals, soaps, cosmetics <br /> or alcohol YES NO <br /> • Is there any information you feel you should provide to the <br /> Body art practitioner? YES NO <br /> If Yes to any of the above please explain: <br /> Your Full Name: First, Middle, Last Date of Birth Age Today <br /> Your Address: STREET CITY STATE ZIP <br /> Your Phone: Todays Date <br /> Client Signature Parent/ Legal Guardian (Minor's PIERCING) <br />