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CLIENT INFORMATION SHEET <br />NAME DOB DA <br />ADDRESS CITY <br />PHONE NUMBER EMAIL <br />PROCEDURES DESIRED: <br />PRACTITIONER NOTES: <br />NEEDLE: PIGMENT: <br />NOTES: <br />TOUCHUP: <br />Have you ever had a cold sore? Yes No <br />Ifyes, you must contact your physician for a prescription of ZOVIRAX capsules, an <br />antibiotic which prevents cold sores. <br />How did you hear <br />about <br />us? <br />Diabetes <br />Are. you currently <br />under <br />the care <br />of a physician? Yes No <br />Ifyes, why? <br />Physician's name: <br />Do you talee antibiotics when going to the dentist? Yes No <br />Ifyes, why? <br />Please check any that apply to you: <br />o <br />Allergies <br />o <br />Diabetes <br />o <br />Moles or freckles at site of tattoo <br />o <br />Skin Problems <br />o <br />Hepatitis <br />o <br />Scarring (Keloids) <br />o <br />Bleeding Disorder <br />o <br />Eye Problems <br />o <br />Heart Problems <br />o <br />Epilepsy <br />o <br />Hcmo hilia <br />o <br />Other <br />Any risk factors. for Bloodborne Pathogen exposure? YesNo <br />Are you presently taking any medication which thins the blood? Yes No <br />Are you taking any other medication? Yes No <br />Ifyes, please explain: <br />Are you pregnant or nursing? Yes No <br />Do you wearcontact lenses? Yes No <br />I agree that I have filled this out truthfully, to the best of my lrnowledge. <br />