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AQUENT MEDICAL HISTOmNIf <br /> Name Email <br /> Address city State Zip <br /> ell# (_� - o or (�) - <br /> Emergency Contact Phone# <br /> Are you over 18 yrs of age? DOB DL# <br /> Procedure (circle all that apply) Eyeliner/Eyebrows / Lips/Tattoo Removal / Lash Liner <br /> How long has it been since you last ate? Do you wear contacts lens?YES/ NO <br /> Are you currently under doctor care for any health condition, please explain <br /> Do you have any additional allergies such metals, latex, cosmetics, or anabiotic`s? <br /> Do you have any medication that might affect healing of the body art you wish to receive? <br /> Do you have any other medical or skin condition at the procedure site (Cold sores/Blisters/herpes) <br /> that will affect the outcome of the procedure? <br /> Have you ever been prescribed anabiotic`s prior to dental or surgical procedures? <br /> Please vide any information you feel you should rvi to the body art practitioner and other <br /> medical conditions ( pregnancy, hemophilia, bleeding disorders, cardiac valve disease, herpes infection, <br /> diabetes, etc.): <br /> Have you ever had hepatitis? YES / NO Ifs ? Please explain <br /> Have you ever had any fillers or Botox procedures? YES f NO If so, when? <br /> List any medications that you Have taken in the pasto weeks? <br /> Back Page <br />