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__________________________________________________________________ <br /> <br /> INFECTION, ADVERSE REACTION, ALLERGIC INCIDENT REPORT <br /> <br /> <br /> <br /> <br />Date Reported: _____/______/______ Date of Procedure: _____/______/______ <br /> <br />Date Mailed: ______/______/_______ <br /> <br />Client Name: __________________ Address: _______________________________________ <br /> <br />Home Phone: __________________ City: ___________________ State:________ Zip: ______ <br /> <br />Materials Used: <br />____________________________________________________________________________________ <br /> <br />____________________________________________________________________________________ <br /> <br />____________________________________________________________________________________ <br /> <br />____________________________________________________________________________________ <br /> <br /> <br />Description of Problem: <br /> <br />____________________________________________________________________________________ <br /> <br />____________________________________________________________________________________ <br /> <br />____________________________________________________________________________________ <br /> <br />____________________________________________________________________________________ <br /> <br />____________________________________________________________________________________ <br /> <br /> <br /> <br />Attending Physician: _____________________________________________________________ <br /> <br />Address: _______________________________________________________________________ <br /> <br />Phone: ________________________________________________________________________