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LIENT INFORMATION SHEET <br /> NAME Date of Birth: <br /> ADDRESS <br /> PHONE <br /> May we contact you at this number if necessary? II Yes ❑No <br /> EYEBROW PROCEDURES DESIRED: ❑Microblading ❑Manual Shading ❑Ombre Powder ❑Microshading <br /> How did you hear about my service? ❑Instagram ❑Facebook ❑Internet/Website <br /> ❑Referred by Family/Friend (Name of referral: ) <br /> Are you currently under the care of a physician? ❑Yes ❑No <br /> If yes, why? <br /> Physician's name: <br /> Do you take antibiotics prior to surgery or dental procedures? QYes ❑No <br /> If Yes, Why? <br /> Do you suffer from: ❑Allergies to Latex ❑Allergic reactions to Antibiotics ❑ Hepatitis <br /> ❑Moles or freckles at site of tattoo ❑Heart problems or Cardiac valve disease <br /> ❑Hemophilia or other bleeding disorders ❑Diabetes ❑Skin Problems <br /> ❑Scarring(Keloids) ❑Eye Problems ®Epilepsy ❑Herpes infection at site of tattoo <br /> Other risk factors for bloodborne pathogens (if none,indicate N/A) <br /> Are you presently taking any medication which thins the blood? EI-Yes ❑No <br /> If yes,please explain: <br /> Are you taking other medications? ❑ Yes ❑ No <br /> Are you pregnant or nursing? ❑ Yes ❑ No <br /> Do you wear contact lenses? ❑ Yes ❑ No <br /> I understand that my deposit of$ is NON-Refundable.My deposit will be applied towards my total price.If I cancel my <br /> appointment,my deposit is forfeited.Reschedules require 48hrs prior notice,otherwise there will be an additional charge of$ <br /> to reschedule my appointment. <br /> *Signed: (Client) Date: <br />