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AUTHORIZATION/CONSENT <br /> By signing this document, you verify that the information you disclosed is accurate and <br /> correct; that you have read and agree to the statements marked and/or initialed; and <br /> you provide consent and authorization for treatment. <br /> Client Full Legal Name (print <br /> clearly): <br /> Client <br /> Signature: Date: <br /> For Office Use <br /> Client <br /> Name: <br /> Artist <br /> Name: <br /> Artist <br /> Signature: <br /> Date of Procedure: Needle lot <br />