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- Today's Date*
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Format: (000) 000-0000.
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- Birthday *
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Format: (000) 000-0000.
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- Heart Conditions/angina/blood pressure problems?*
- Epilepsy?*
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- Haemophilia/anemia/other?*
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- Blood disease or virus? (ex. HEP B, HEP C, or HIV)*
- Problems with skin healing in past? (ex. Lupus, Psoriasis, Eczema)*
- Type I or Type II Diabetes?*
- "Lumpy" or raised scars? (Keloid Scars)*
- Known allergic responses?*
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- Take any prescribed medication regularly?*
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- Pregnant or breastfeeding?*
- Prone to fainting or light headedness?*
- Known/previous reaction to dye pigment?*
- Other relevant information?*
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- Currently under the influence of any drugs or alcohol?*
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- Should be Empty: