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N ICY) <br /> (D O <br /> N a) <br /> L0 a) <br /> ry <br /> n z used.Provide END <br /> LostNeme <br /> ---____Flrel Neme phone N <br /> Address <br /> A;11 <br /> of 9p re / <br /> CllenloeleolBldh NemeolGlerdnpalaelknanhod ' <br /> I Nemeolerutltbner � �' <br /> shable.Repair/ <br /> 0p8/ <br /> I accept this body piercing.Client slpneturo <br /> h <br /> I D. +� e00d t <br /> 4 <br /> 1ePair Vde <br /> di <br /> la, <br /> ce <br /> I <br /> tie¢ <br /> v <br /> MEDICALHISTOBY <br /> Please circle Yes or No for any condltions listed below that apply to you, <br /> Diabetes YIN Hemophilia Y/N Pregnant/Nursing YIN Skin Conditions YIN <br /> Epilepsy YIN <br /> BloodTh nets V/N T.B. YIN Asthma YIN <br /> Fainting or Dizziness Y/N Herpes YIN Eczema/Psoriasis YIN Allergic reactions to YIN <br /> ola ProSrJA latex <br /> Heart Cond(tlon Y/N HIV/AIDS Y/N Scardng/ YIN Allergic reaplonsto YIN <br /> KeloldlAg antibiotics <br /> -a Do you have a Cardiac Valve Disease? <br /> CL <br /> c <br /> How long has been since you last ate? <br /> o ao <br /> to Do you have any allergies? <br /> rn � <br /> c� <br /> v Do you use any medications that might affect the healing of the body art you wish to ieceiuel <br /> o c <br /> 0 o Do you have any other medical or skin condilions That may affect the outcome of your procedure? <br /> m <br /> Are there any other risk factors for bloodborne pathogens that the body art practitioner needs to be aware ot? <br /> O U_ <br /> c <br /> J a) <br /> N Have you ever been prescribed antibiotics prior to denial or surgical procedures? <br /> a) cn , <br /> Is there any other informalion you feel that you should provide to the body art practitioner? _ <br /> o Y w <br /> O <br /> e4 <br /> .� �, ca � ,. � .,� r. � IMPd'Lo Inns• fY(J� ybv �� �yt?M ��I <br /> to N 6 t '' k: <br /> O '� O (n <br /> O <br />