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0 <br /> CD <br /> jotform.com + [D <br /> FP © ,, FORM - Jotform Form... O ADORN BEAUTY INK C... O ME TATTOO CONSENT... !; My sign Documents I J... <br /> SETTINGS PUBLISH Preview Form Ift <br /> Epinephrine <br /> Lidocaine <br /> + Hydrocortisone <br /> . Hydroquinone or Nickel/Metals <br /> 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 /> Dole ' � • - • <br /> Medical clearance is required if you are under the care of a phy <br /> medical condition is current. <br /> • • • ell Talk <br /> ** if you book an appointment with any of the above restrictions and <br />