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Last Name <br />First Name Phone # <br />Address Scity State Zip <br />Street Apt. Zx <br />Client Date of Birth Name of Piercing & Location on body Name of Practitioner <br />I accept this body piercing. Client Signature <br />so <br />MEDICAL HISTORY <br />W <br />Please circle Yes or No for any conditions listed below that apply to you. <br />Diabetes <br />Y/N <br />H er+ophiilia <br />Y/N <br />Preg <br />T.B. <br />e 'n ,Svc er <br />Blood Thinners;EEcze <br />Y/N <br />Epilepsy <br />Y/N <br />Fainting or Diuiness <br />YJN <br />}rpes <br />,'✓i �E'c, o .g c� <br />�o e vre s1 e <br />Heart Condition <br />Y/N <br />HIV/AIDS <br />Y/N <br />Do you have a Cardiac Valve Disease? <br />How long has been since you last ate? <br />Date <br />Want/ Nursin4YIN <br />Skin Conditions <br />YJN <br />T.B. <br />Asthma <br />Y/N <br />ma / Psorlasis Y/N Allergic reactions to Y/N <br />latex <br />Scarring 1 Y/N Allergic reactions to Y/N <br />0..1..7.11„e antibiotics <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 />