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Last Name First Name Phone# <br /> Address <br /> Street Apt City State Zip Code <br /> Client Date of 3irth Name of Piercing&Location on body Name of Practitioner <br /> I accept this body piercing. Client Signature Date <br /> I.D. I.D. <br /> MEDICAL HISTORY <br /> Please circle Yes or No for any conditions listed below that apply to you <br /> Diabetes Y/N Hemophilia Y/N Pregnant/Nursing Y/N Skin Conditions Y/N <br /> Epilepsy Y/N Blood Thinners or Y/N Tuberculosis Y/N Asthma Y/N <br /> other Bleeding <br /> Disorder <br /> Fainting or Dizziness Y/N Herpes Infection Y/N Eczema/Psoriasis Y/N Allergic Y?N <br /> at Procedure Site reactions to <br /> latex <br /> Heart Condition Y/N HIV/AIDS Y/N Scarring/Keloiding Y/N Allergic Y/N <br /> reactions to <br /> antibiotics <br /> Do you have a Cardiar Valve Disease? <br /> How long has it been since you last ate? <br /> Do you have any allergies? <br /> Please list arry medicztions you are taking: <br /> Do you have any other medical or skin conditions that may affect the outcome of your procedure? <br /> Are there any other risk factors for bloodborne pathogens that the body art practitioner needs to be aware <br /> of? <br /> Have you ever been prescribed antibiotics prior to a dental or surgical procedure? <br /> Is there any other information you feel that you should provide to the body art practitioner? <br /> L <br />