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Versailles Salon And Spa <br /> 1010 Central Ave* Traa,CA 95376 ® Salon(209)836-1505 Cell(209)275-9133 <br /> Infection,Adverse Reaction,Allergic Reaction Incident Report <br /> To Be Forwarded Within 5 Days of Incident to <br /> California Department of Health <br /> Drugs and Medical Devices Division <br /> (916)558-1784 <br /> Date Reported / / Date of Procedure: <br /> Date Mailed to CA Department of Health: <br /> Client Name: Address: <br /> Work Phone: City: <br /> Home Phone: State&Zip: <br /> Color(s)Used: <br /> Description of problem: <br /> Attending Physician: <br /> Address: <br /> Phone: <br /> C:\Users\Versailles 2\Downloads\2017 REVISED Consent Form TEMPLATE.docx Rev:1$!5/2016 Page 8 of 8 <br />