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CLIENT INFORMATION <br />PLEASE TAKE LD OUT FOR A COPY TO BE MADE <br />NAME DOB DATE <br />ADDRESS <br />PHONE <br />How did you hear about us? <br />EMAIL <br />MEDICAL INFQRMATION <br />Are you currently under the care of a physician? If so, why? <br />CITY/ZIP <br />If under Physicians Care, please provide Physician's Name &Phone Number: <br />Are antibiotics requited prior• to surgeries or dental procedures? Yes/No <br />Are you currently taking any medications that thin blood? Yes/No <br />Are you taking any medication? Yes/No <br />If yes, please explain: <br />Are you currently pregnant or nursing? Yes/No <br />Do you wear contact lenses? Yes/No If yes, please remove them prior to procedure. Do you <br />have any risk factors for Bloodborne Pathogen Exposure? (compromised immune system) Yes/No <br />Please circle any below that apply to you: <br />Allergies Diabetes <br />Moles or Freckles at tattoo site Hair/Skin Problems (eczema/alopecia) <br />Hepatitis Scarring at tattoo site (keloids) <br />Bleeding Disorder Eye Problems <br />Heart Problems Epilepsy <br />Hemophilia Other: <br />CLIENT INFORMATION AND MEDICAL HISTORY CONTINUED <br />Do you have a history of allergic reactions to latex? Yes/No <br />