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CLIENT INFORMATION SHEET <br /> NAME; <br /> ADDRESS: DATE OF BIRTH: <br /> PHONE: <br /> !Vta✓ we contact you at this number if necessary? Yes <br /> II ❑No <br /> P,--:OCEDURE(S)DESIRED: ❑Microbladin <br /> g ❑Ombre Powder Combo/Hybrid - <br /> ❑ Fineline/Tiny Tattoo Li Blush <br /> ❑ p ❑Eyeliner ❑Scalp Micro-Pigmen ation <br /> How did you hear about my service? ❑Instagram ❑Facebook ❑Internet/Website - <br /> ❑Referred by Family/Friend(Name of referral: <br /> Are oou currently under the care of a physician? ❑Yes []No <br /> If yes,why? <br /> Physician's name: - <br /> Do yok take antibiotics prior to surgery or dental procedures? ❑Yes []No <br /> If Yes, Why? <br /> Do yon suffer frim: ❑Allergies to Latex ❑Allergic reactions to Antibiotics ❑ Hepatitis <br /> ❑Moles or f-eckles at site of tattoo ❑Heart problems or Cardiac valve disease <br /> ❑Hamophili a or other bleeding disorders ❑Diabetes ❑Skin problems <br /> ❑Sca_-ring(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? <br /> El If yes,pease explain: Yes E3 No <br /> Are.you taking other medications? ❑ Yes ❑ No <br /> Are y oL pregnant or nursing? ❑ Yes ❑ No <br /> Do you wear cotrtact lenses? ❑ Yes ❑ No <br /> I und:rstand that my deposit of$ is NON-Refundable.My deposit will be applied towards my total price.If I cancel my <br /> appointmen,my deposit is forfeited.Reschedules require 48hrs prior notice,otherwise there will be an additional charge of$ <br /> to reschedule my appointment <br /> Sign`ture: <br /> Date: <br />