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Yes No—Keloid <br /> Yes No—Vega n <br /> Yes No—Cancer <br /> Yes No—Waxing <br /> Yes No-Tan by booth or sun <br /> Yes No-Difficulty numbing with dental work or requirements for antibiotics prior to surgery or dental <br /> procedures. <br /> Yes No -Taking blood thinners such as:Aspirin, Ibuprofen, alcohol,etc. <br /> Yes No-Allergic reaction to any medications such as Lidocaine,alcohol,etc. <br /> If so history of allergic reactions to antibiotics: <br /> Yes No -Allergies to metals, latex,food,etc. <br /> Yes No-Any diseases or disorders not listed: <br /> Yes No-Do you use skin care products containing Retin-A,glycolic acid or alpha hydroxyl? <br /> Yes No—History of cardiac valve disease <br /> Any other risk factors for blood borne pathogens: <br /> Please list any medication or vitamins you're presently taking: <br /> I agree that all the above information is true and accurate to the best of my knowledge. <br /> Signature Date: <br /> 2 <br />