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Port City Ink Client Medical History Form <br /> CLIENT INFO <br /> Name: Age: DOB: <br /> Phone: Address: <br /> Emergency Contact: Phone: <br /> PROCEDURE INFO <br /> Circle the type of body art being performed: <br /> Tattoo Piercing <br /> Procedure Site: Description of Procedure: <br /> MEDICAL HISTORY <br /> Please circle any conditions listed that apply to you: <br /> Diabetes Tuberculosis Asthma Epilepsy <br /> Blood Thinners Eczema/Psoriasis latex Allergies Fainting/Dizziness <br /> Scarring/Keloiding Antibiotic Allergies Pregnant/Nursing Skin Conditions <br /> Hemophilia or other History of cardiac valve History of herpes Any other risks for <br /> bleeding disorders disease infection at the blood borne pathogens <br /> procedure site <br /> When is the last time you ate? <br /> Are you taking medications? Do you have any allergies? <br /> Have you ever been prescribed antibiotics prior to dental/surgical procedures? <br /> Do you have any other medical or skin conditions that may affect the outcome of your tattoo or <br /> is there any other information you feel you should provide? <br /> Client Signature: Date: <br /> PRAC"WNER: Type of Wndfkobm ProWded: I lure reviewed the df"t's koormation presorted <br /> and have provNed kdonmtion an aftercare. <br /> MkoWs license Passport Birth cer w—w �R of Prrstttlotsar <br /> BODY ART FAOL rY: at/tereare averviewed aid prWMed <br /> INSTRUMEW L06 <br /> Date supplier tnstnrnent/Nee& WID tt Steriization Date bViration <br />