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0 W <br /> 'ok <br /> Versailles Salon And Spa <br /> 1010 Central Ave* Tracy,CA 95376 ® Salon(209)836-1505 Cell(209)275-9133 <br /> Name: <br /> Home Address: <br /> No.&Street City State Zip <br /> Work Address: <br /> No.&Street city State Zip <br /> Home Phone:( Work Phone: <br /> Employer. Occupation: <br /> Are you now or have you been under the care of a physician within the last two years.? <br /> If yes,please provide Physician's Name, address and phone number. <br /> Person to contact in an emergency: <br /> Name <br /> Address&Phone No. <br /> List all medications you are currently taking,including Retin A,Glycolic Acid and Acutane: <br /> Have you been prescribed antibiotics prior to surgical or dental procedures: <br /> Have you recently undergone a skin peel? <br /> What products do you use for skin care? <br /> Are you pregnant or breastfeeding? <br /> Are you allergic to latex: Are you allergic to any antibiotics: <br /> Do you have or have Vol] had any of the following conditions(answer Yes or No): <br /> Abnormal Heart Condition Eve Surgery or Injury <br /> Cold Sores Blepharoplasty(eye! id surgery) <br /> Herpes Simplex at procedure site Visual Disturbances <br /> —Hemophilia Cancer <br /> High or Low Blood Pressure Tumors/Growths/Cysts <br /> Prolonged Bleeding Chemotherapy/Radiation <br /> Circulatory Problems Are you pregnant? <br /> —Epilepsy Hepatitis <br /> Diabetes Do you wear contact lenses? <br /> Fainting Spells/Dizziness Do You use tobacco products? <br /> Cataracts Cardiac Valve Disease? <br /> Glaucoma Eye Drops or Ocular Medications? <br /> "Dry Eye" Hyper-pigmentation? <br /> Come Abrasions Currently taking aspirin/ibuprofen? <br /> When was your last eye exam? <br /> Examining Physician: <br /> Signature Date <br /> C:\Users\Versailles 2\Downloads\2017 REVISED Consent Form TEMEPLATE.docx Rev.12/5/2016 Page 5 of 8 <br />