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BODY <br /> ktL, tNE , y f�FIFASr WAI \- f RST R !�.r N' .--,-.ARr :_aR CAMOUFLAGE TATTOOING <br /> Thank you for trusting Body Regenesis Ilc.with your cosmetic <br /> tattooing services. Please fill out& return the waiver below prior to <br /> your appointment.Thankyou. <br /> Name(required) First Name Last Name <br /> Date of birth(required) <br /> Address(required) <br /> City(required) State(required) <br /> Zip code(required) Email(required) <br /> Phone(required) <br /> Valid ID Acknowledgement(required) <br /> I understand that I am required to present a valid US government issued ID at the time of my procedure <br /> Driver's License <br /> Passport <br /> What procedure are you having done today?(required) <br /> Stretch Mark Camouflage Tattoo Lip Blushing <br /> Scalp Micropigmentation Scar Camouflage Tattoo <br /> Areola Repigmentation Other(please list below) <br /> If other,please list here: <br /> How did you hear about Body Regenesis LLC.?(required) <br /> CONFIDENTIAL MEDICAL HISTORY: <br /> 1 <br />