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Please initial next to the following <br /> I have no history of: <br /> Hemophilia or any other bleeding disorders <br /> Herpes infection at procedure site <br /> History of allergic reactions to antibiotics <br /> History of cardiac valve disease <br /> Requirements for antibiotics prior to surgery or dental procedures <br /> I have no other risk factors for bloodborne pathogens. If yes, please state below. <br /> I am aware that the pigments used are not FDA approved and health consequences are unknown. <br />