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ICAI� STORY ITESTIO <br /> Name: First Middle <br /> Last <br /> Sex: <br /> Date of Birth: <br /> Address: <br /> Phone: <br /> Emergency Contact: <br /> Please check any conditions listed below that apply to you. <br /> Diabetes Hemophilia <br /> T.13 Asthma <br /> Eczema/Psoriasis Allergic reactions to <br /> Epilepsy Blood Thinners latex <br /> Fainting or history of herpes <br /> Scarring/Keloiding Allergic reaction to <br /> antibiotics <br /> Dizziness infection at the <br /> procedure site <br /> Pregnancy/ Skin Conditions other risk factors for <br /> history of cardiac blood borne pathogens <br /> valve disease Nursing <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 body art 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 /> Is there any other information you feel you should provide to the body art practitioner? <br /> The information I have provided is complete and true to the best of my knowledge. <br /> Date:Signature of Client: <br />