Quick checklist

Name

Do you have any of the following?

Latex allergies

Yes

No

Pacemaker or any implantable devices?

Yes

No

Bleeding disorder?

Yes

No

Blood thinners?

Yes

No

If so what?

Infectious disorder? (HIV or Hepatitis C).

Yes

No

Are you going back to see your doctor today?

Yes

No

Todays date

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