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A <br /> Yes No — Cancer (year ) <br /> Yes No —Accutane or Acne treatment <br /> Yes No — Chemotherapy/Radiation <br /> Yes No —Tan by booth or sun <br /> Yes No —Tumors/Growths/Cysts <br /> Yes No — Difficulty numbing with dental work <br /> Yes No —Taking blood thinners such as: Aspirin, Ibuprofren, alcohol, Coumdan, ect. <br /> Yes No — Do you have any other risk factors for bloodborne pathogens? <br /> Yes No —Allergic reaction to any medication such as Lidocaine, Tetracaine, <br /> Epinephrine, Dermacaine, Benzyl Alchohol, Carbopol, Lecithin, Propylene glycol, <br /> Vitamin E Acetate, ect. <br /> List <br /> Yes No —Allergies to metals, food, or latex, etc. <br /> Yes No —Any diseases or disorders not <br /> listed: <br /> Yes No — Do you use skin care products containing Retin-A, glycolic acid or alpha <br /> hydroxyl? <br /> Please list any medications 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 /> Sign: <br /> Date: <br />