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Sharon Cruz Ortified MicroBlade Artist ( 612-0430 <br /> Date: <br /> Name: <br /> Address: <br /> City: ST: Zip: <br /> Home Phone: Work Phone: <br /> Referred By: <br /> Fees Discussed: <br /> Additional Fee: <br /> Procedure Request: <br /> Areas of Concern: <br /> Technician Name: <br /> Pigment(s)Used: <br /> Lot# &Batch#: <br /> Expiration Date(s): <br /> Machine(s)Needle(s) Used: <br /> Anesthetic Used: <br /> Touch-up(s) Done On: <br /> Additional procedures: <br /> Page 7 of 8 <br />