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Client/Consent form ( page2 of 2) <br />Questionnaires: <br />siteI <br />History of herpes infection at the procedure <br />- History of allergic reactions to latex. <br />History of allergic reactions to antibiotics. <br />History of hemophilia or other bleeding <br />disorders. <br />History of cardiac valve disease. <br />Requirements for antibiotics prior to surgery or <br />dental procedures. <br />Other risk factors for blood borne pathogens. <br />