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el(O.l <br /> vel <br /> Permanent Makeup& Tattoo <br /> Client's Name' <br /> Date of Birth <br /> Street Address <br /> City <br /> State <br /> Zip <br /> Phone Number <br /> Email <br /> Emergency Contact <br /> Emergency Phone Number <br /> Do you presently have or previously had any of the following:(Circle yes or no) <br /> O History of Herpes at the procedure site <br /> O Diabetes <br /> D Hepatitis(A,B,C,D) <br /> D History of hemophilia or other bleeding disorders <br /> 0 History or cardiac valve disease <br />