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Canvas Tattoo — 304 W Harding Way #B, Stockton CA 95204 <br />July 24, 2025 <br />PHOTO 6: Medical questionnaire for permanent cosmetics. <br />KILLER BEAUTY BY KATRINA <br />CLIENT INFORMATION SHEET <br />AEDIE)RES <br />May we contact you at this number if necessary? <br />Eyebrow Procedure(s) desired: Microblading _Ombre Powder _Combo _ <br />How did you hear about my service? _ Instagram Facebook <br />Referred <br />Family/Friend who referred you_ <br />Are you currently under the care of a physician"? Yes <br />No <br />If Yes, why? <br />Physician's Name: <br />E)o you take antibiotics prior to surgery or dental procedures? <br />Yes No <br />If Yes, why? <br />no you suffer from: <br />_Allergies to latex _Allergic reactions to Antibiotics <br />_Hepatitis <br />Moles/Freckles at tattoo site _Heart problems or cardiac <br />valve disease <br />Diabetes S ca m n g(ke to id s) <br />_Eye Problems <br />_Skin Problems _Epilepsy <br />_Herpes infection at site <br />_Hemophilia or other bleeding disorders <br />Other risk factors for bloodbome pathogens (if none, indicate N/A): <br />Are you presently taking any medication which thins the bl(:>od? <br />Yes No <br />If Yes, please <br />explain - <br />Are you taking other medications? Yes NoAre you pregnant or nursing? Yes No <br />IDo you wear contact lensas? Yes No <br />I understand that my deposit of $ is NON -Refundable_ My deposit will be applied <br />towards my total price_ If 1 cancel my appointment, my deposit is forfeited. Reschedules require <br />48 hrs prior notice, otherwise there will be an additional charge of $50 to reschedule my <br />appointment <br />SIGNED <br />ient) DA <br />PR0523952 <br />Sandip Singh, REHS Page 6 of 8 <br />