Laserfiche WebLink
Date of birth: <br />Sex: <br />Address: <br />Emergency Contact: <br />Phone number: <br />Please check any conditions that apply <br />Diabetes Hemophilia <br />Blood thinners <br />Tuberculosis Asthma <br />—Allergy to latex <br />Epilepsy Psoriasis <br />^ Herpes <br />Dizziness Scarring <br />Heart condition <br />Skin condition Pregnancy <br />a Allergy to antibiotics <br />How long since you last ate <br />Do you have allergies <br />Do you take medications that may affect the healing of your tattoo <br />Do you have medical or skin conditions <br />Have you ever been prescribed antibiotics prior to surgery or dental procedures <br />Is there any other information you feel you should provide <br />ANTIBIOTIC RECOMMENDATION: People who are at high risk for infections should take one <br />dose of antibiotic by mouth one hour before procedure. <br />THE INFORMATION I HAVE PROVIDED IS COMPLETE AND TRUE TO THE BEST OF MY <br />KNOWLEDGE. <br />SIGNATURE OF CLIENT DATE <br />