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Artist: Contact: <br /> Infection, Adverse Reaction,Allergic Reaction Incident Report <br /> Date Reported: / J ]—Date of Procedure: <br /> Date Mailed: <br /> Client Name: Address: <br /> Work Phone: City: <br /> Home Phone: State &Zip: <br /> Cclor(s) Used: <br /> Description of problem: <br /> Attending Physizian: <br /> Address: <br /> Phone: <br /> /Users/shaunafox/Desktop/2017 REVISED Consent Form(UPDATED)(2).dmx Rev:145/2016 Page 8 of 8 <br />