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N T N .Wp 0 <br /> X O0 Q N N <br /> 0 � g3 <br /> d <br /> rD N W <br /> m N i <br /> r=ir CLIENT INFORMATION SHEET <br /> NAME.�ij//i i DATE OF BIRTH.43/1.5/1 eo <br /> ADDRESS:_�(n7C/Jo�i/Tti���I SFnr 91'7 � }C 14 95Z/>5 O n <br /> PHONE. <br /> Z 3 <br /> May we contact you at this number if necessary? En Yes []No r) <br /> O D <br /> PROCEDURE(S)DESIRED: �Zf Micmblading ❑Ombm Powder Combo/Hybnd Bmws n0 W <br /> ❑ Fiaelim Body Tattoo ❑Lip Blush Tattoo ❑EyeImcrTanoo ❑Scalp Micro-Pigmentation 3 N <br /> p Fr <br /> m 1p <br /> iZ <br /> How did you hear about my service? ❑instagmm ❑Facebook ❑Intemet/Website <br /> ' C]Referred by Family/Friend(Name of referral SGI P <br /> 00 <br /> Are you currently under the care of a physician? ❑Yes 10 No O <br /> .t <br /> If yes,why? ? <br /> rD <br /> Physician's name. <br /> d <br /> Do you take antibiotics prior to surgery or dental procedures? Elyes g]No n <br /> If Yes,Why? 0 <br /> u, <br /> Do you suffer from: ❑Allergies to Latex ❑Allergic reactions to Antibiotics ❑Hepatitis O <br /> ❑Moles or freckles in site of tattoo ❑Heart problems or Cardiac valve disease 0 <br /> 0 <br /> ❑Hemophilia or other bleeding disorders ❑Diabetes ❑Skin ProblemsCT <br /> 0 <br /> ❑Scarring(Keloids) ❑Eye Problems ❑ Epilepsy ❑Herpes infection at site of tattoo <br /> rD <br /> Other risk factors for bloodbome pathogens(if crone,indicate NIA): <br /> d <br /> Are you presently taking any medication which thins the blood? T <br /> ❑Yes [YNo 1- <br /> Signature: 0on <br /> If yes,please explain: M <br /> Are you taking other medications? ❑ Yes ® NoAre ou re y p gran[or nursing? ❑ yes ® No0 <br /> Do you wear contact lenses? ❑ Yes W No <br /> I undersand ont^w deposit of i_is NON-Refundable.My deposit will be applied towards my mud prim.B 1 canaappointment my deposit is fodehed.Reschedules require 48hrs prior mom,odmwis,them will be m additional charge of Sm reschedule my agmonem C/ Date. I <br /> 0 <br /> O <br /> N <br /> A <br /> A <br /> O <br /> N <br /> O <br /> F+ <br /> A <br />