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cardiac valve disease <br />Diabetes <br />Eye Problems <br />Skin Problems <br />Scarring(keloids) <br />Epilepsy <br />Herpes infection at site <br />Hemophilia or other bleeding disorders <br />Other risk factors for bloodborne pathogens (if none, indicate <br />N/A): <br />Are you presently taking any medication which thins the blood? <br />Yes No <br />If Yes, please <br />explain: <br />Are you taking other medications? Yes <br />Are you pregnant or nursing? Yes <br />Do you wear contact lenses? Yes <br />No <br />No <br />No <br />I understand that my deposit of $ is NON -Refundable. <br />My deposit will be applied towards my total price. If I cancel <br />my appointment, my deposit is forfeited. Reschedules require 48 <br />hrs prier notice, otherwise there will be an additional charge of <br />$50 to reschedule my appointment. <br />SIGNED <br />DATE <br />_(Client) <br />