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0 Versailles Salon And Spa 0 <br /> 1010 Central Ave* TLta,CA 95376® Salon L2091836-1505 Cell(209)275-9133 <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 /> C:\Users\Versailles 2\Downloads\2017 REVISED Consent Form TENIPLATE.docx Rev:12/5/2016 Page 7 of 8 <br />