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BODY _ <br /> sr RETCH MARK/SCAR CAMOUFLAGE TATTOOING P \L_ I �- AS [[ ` I ` IR <br /> Thank you for trusting Body Pegenesis Ilc.with your cosmetic <br /> tattooing services. Please fill out&return the waiver below prior to <br /> your appointment.Thankyou. <br /> Name(required) First Name Lost Name <br /> Date of birth(required) <br /> Address(required) <br /> City(required) State(required) <br /> Zip code(required) Email(required) <br /> Phone(required) <br /> Valid ID Acknowledgement(required) <br /> I understand that I am required to present a valid US government issued ID at the time of my procedure <br /> Driver's License <br /> Passport <br /> What procedure are you having done today?(required) <br /> Stretch Mark Camouflage Tattoo Scar Camouflage Tattoo <br /> Do you have a history of herpes at the procedure site?(required) <br /> ❑ )IS <br /> ❑ \O <br /> Do you have a history of allergic reactions to antibiotics?(required) <br /> ❑ ll1�1 <br /> Do you have a history of cardiac valve disease?(Required) <br /> ❑ llti <br /> Are you currently using medication, including being prescribed antibiotics prior to dental or surgical procedures?(required) <br /> ❑ )IS <br /> ❑ \0 <br /> 1 <br />