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Do you have any of the following Medical Conditions? (please check all that apply) <br /> Cancer <br /> Diabetes <br /> Hemophilia or other bleeding disorders <br /> Keratosis <br /> Vitiligo <br /> HIV/AIDS <br /> Hepatitis <br /> Keloids <br /> High Blood Pressure <br /> Herpes at the procedure site <br /> Arthritis <br /> Seizure <br /> Heart Condition/cardiac valve disease <br /> Blood clotting <br /> Skin Disease <br /> Hormone Imbalance <br /> Thyroid Imbalance <br /> Jaundice <br /> Requirements for antibiotics prior to surgery or dental procedures <br /> Other risk factors for blood borne pathogens <br /> If yes, please provide more information regarding your condition. <br /> Medical clearance is required if you are under the care of a physician and the medical condition is current. <br /> https://foriii.jotfor-m.com/231451878214154 5/12/25, 2:10AM <br /> Page 7 of 9 <br />