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Clin-ink 77 Consent Form

To my knowledge i do not or have not suffered from any of the following:

Heart Disease or taking any blood thinning medication
Eczema or any skin conditions
Inpetigo or any other contagious skin rash
Epilepsy or any other seizure inducing conditions
Disabetes (if yes please specify the type in the text box below)
HIV infection, Hepatitis A, B or C
Acne, psoriasis or Cellulitis
Have you consumed alcohol or drugs in the last 24 hours?
Are you pregnant?
Any Allergic Responses? Latex/Plasters (if yes please specify in the text box below
Thanks for submitting!
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