Medical Questionnaire

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Client Information

Client Name*

First Name*

Last Name*

Address ***US Residents ONLY***

Address Line 1

Address Line 2

City

State

ZIP Code

Date of Birth*

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Month

Day

Year

Email Address - Copy*

Cell Phone ***US Residents ONLY***

Driver's License*

Medical History

Medical History*

None Allergic to Latex Epilepsy Fainting or Dizziness Heart Condition Asthma Tenderness Hemophelia Bleeding Disorder Blood Thinners Herpes Pregnant/Nursing HVB TB Eczema/Psoriasis Scarring/Keloiding Skin Conditions Fever Hepatitis

Other: Other Value

Check any past/current problems

When did you last eat?*

Do you have any allergies?*

Are you taking any medications that might affect the healing of the body art you are receiving?*

Is there any other information you would like to provide to the body art practitioner?*

Do you have any medical or skin conditions that may affect the outcome of your procedure?*

Signature of Client*

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Artist's Name*

First Name*

Last Name*

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