Laserfiche WebLink
Last Name <br /> First Name Phone# <br /> Address S city State Zip <br /> Street Apt. tt <br /> Client Date of Birth Name of Piercing&Location on body Name of Practitioner <br /> I accept this body piercing. Client Signature <br /> Date _— <br /> LD_ <br /> LD. <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 YIN Skin Conditions Y/N <br /> e n 150 er Asthma Y/N <br /> Epilepsy Y/N Blood Thinners YIN <br /> llergic reactions to YIN <br /> Fainting or Dizziness Y/N riles YjN Eczema/Psoriasis Y/N A <br /> ,',� �'��� �- latex <br /> pro e vre st e <br /> Scarring I Y/N Allergic reactions to Y/N <br /> Heart Condition Y/N FitV/AIDS Y/N Keioiding antibiotics <br /> Do you have a Cardiac Valve Disease? <br /> How long has 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 /> Are there any other risk factors for bloodborne pathogens that the body art practitioner needs to be aware of? <br /> Have you ever been prescribed antibiotics prior to dental or surgical procedures? <br /> Is there any-other information you feel that you should provide to the body art practitioner? <br /> r <br />