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BODY <br /> R E G E N E S I S <br /> STRETCH MARK/SCAR CAMOU'LAGC TATTOOING <br /> Are you currently under medical care?:(required) Yes No <br /> Have you had any cosmetic injections in the last 3 months?(required) Yes No <br /> Have you had Botox/Dysport or any other fillers in the last 2 weeks?:(required) Yes No <br /> Are you pregnant or breastfeeding?(required) Yes No <br /> Do you have any allergies? If yes, please list allergies (required) Yes No <br /> Are you allergic to latex? Yes No <br /> Are you prone to cold sores?(required) Yes No <br /> Are you a hemophiliac?(required) Yes No <br /> Do you take fish oil supplements or blood thinners?(required) Yes No <br /> Do you have diabetes?(required) Yes No <br /> Do you have any heart conditions?(required) Yes No <br /> Do you have high or low blood pressure?(required) Yes No <br /> Do you have Hepatitis A,B or C?(required) Yes No <br /> Are you HIV positive?(required) Yes No <br /> Do you have any contagious diseases?(required) Yes No <br /> Do you have any skin conditions?(required) Yes No <br /> Do you have or have you had cancer?(required) Yes No <br /> Have you been under the influence of drugs or alcohol in the last 24 hours? <br /> Yes No <br /> (required) <br /> Have you had any caffeine in the last 24 hours?(required) Yes No <br /> Are you currently taking any pain medications,over the counter or prescribed? Yes No <br /> (required) <br /> If yes,please list here: <br /> Are you currently taking any immunosuppresants?(required) Yes No <br /> If yes,please list here: <br /> Are you taking Acutone?(required) Yes No <br /> Are you currently using Retin-A or rapid exfoliators?(required) Yes No <br /> 2 <br />