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no <br /> Are you currently under the care of a physician/dermatologist? <br /> yes <br /> no <br /> if YES,explain <br /> current medications <br /> Are you pregnant <br /> yes <br /> no <br /> Are you Breastfeeding? <br /> yes <br /> no <br /> Have you had Hepatitis and Jaundice in the last 12 months? <br /> yes <br /> no <br /> Allergies or Sensitives? (Please check all that apply) <br /> Food <br /> Latex <br /> Epinephrine <br /> Lidocaine <br /> Hydrocortisone <br /> Hydroquinone or NickeWetale <br /> https://form.jottorm.com/231451878214154 5/12/25, 2:10 AM <br /> Page 6 of 9 <br />