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Micoblading &Permanent Makeup <br /> 755 S. Fairmont Ave. Suite E-2 - Lodi, CA 95240 - 209-327-6342 <br /> Permanent Cosmetics Client information <br /> Name <br /> Today's date to of birth <br /> How did you hear about us? <br /> Email address <br /> Address <br /> City State Zip <br /> Best number to reach you <br /> Emergency Contact —Relationship <br /> Phone number of emergency contact <br /> Ethnic Background (Please include all nationalities): <br /> Procedure(s) Desired/Procedure cost: <br /> Shaded Brows $_Microblade $_Brows Combo Eyeliner $ Lips <br /> Fibroblast Skin Tightening: <br /> Clinical outcome of procedure(s) <br /> Please note,the results of your procedure is determined in part by the nature of the pathology <br /> of skin type, but not limited to the following factors: <br /> I- Medication you are currently taking <br /> 2. Skin characteristics: Dryness, oiliness, thickness, sun damage, color, chemically <br /> damaged, sensitivity, rosacea, etc. <br /> 3. Natural skin undertones mixing with pigment color <br /> 4. Alcohol intake, smoking, caffeine intake, sun exposure,and improper skin care <br /> 5. Following pre and post care instructions <br /> 6. In some cases,these factors can or may interfere with acceptance and overall fading of color <br /> pigment <br /> 7. Touch up appointment is required 4-6 weeks after <br />