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IM 'ON Ad 6 Z ti[OZ 'LZ 'Jl0 ;toil paAI ;3;� <br /> CLIENT HISTORY <br /> Name: Date of Birth: <br /> Address: _ <br /> Stree: City suite 7. p <br /> Home Phone: Business Phone: <br /> Cell Phone: May we contact you at these numbers?_ <br /> Email Address: Other ID: <br /> Referred by: — <br /> Emergency Contact: Phone Number: <br /> PROCEDURE(S) DESIRED: Check all of the following that apply. <br /> ❑ Upper eyeliner ❑ Partial eyebrows ❑ Lip liner ❑ Beauty mark <br /> 0 Lower eyeliner ❑ Full.eyebrows ❑ Full lip color ❑ Scar Camouflage <br /> ❑ Other: <br /> ALLERGIES: Check if you have ever had an allergic reaction to any of the following and described what happened below. <br /> ❑ Latex rubber ❑ Tattoo ink/pigment ❑ Novovaine, Lidocaine E: Benzocaine, Tetracaine <br /> ❑ Lanolin ❑ Bacitracin Ointment ❑ Neomycin or polymyxin B ointment <br /> ❑ PABA ❑ Meta](s) ❑ Antibiotics of any kind <br /> ❑ Foods: <br /> Other allergies: — <br /> Reaction: <br /> EYESIEYEBRO`YS: Check all of the following that apply. <br /> C Contact lenses ❑ Dry eyes ❑ Eye makeup sensitivities ❑ Blurred Vision <br /> ❑ Glaucoma C Lasik;eye surgery ❑ Thyroid abnormalities ❑ Alopecia Areata(local) <br /> ❑ ?alopecia Universalis(total) ❑ Pull out lashes/eyebrow compulsively(Trichotiiiomania) <br /> ❑ Other hair loss (describe): <br /> ❑ Eyebrow/Lash tinting ❑ Botox <br /> Date of last service: Date of last service: <br /> Other eye disorders: <br /> LIPS: Check all of the following that apply. <br /> ❑ Cold sores:fever blisters/herpes.Hyes, an antiviral prescription is required prior to any lip procedure. <br /> ❑ Lip injections-Type: Date: <br /> ❑ Other lip augmentation-Type: Date: <br /> ❑ Teeth bleaching-Date: <br /> 6'd ti8916£Z60Z aAilouaolnyuoisioeJd dL6:Z0V[ LZloo <br />