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CLIENT HISTORY <br /> Name: Date of Birth: <br /> Address: <br /> Street City State Zip <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 /> ❑ 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 ❑ Benzocaine, Tetracaine <br /> ❑ Lanolin ❑ Bacitracin Ointment ❑ Neomycin or polymyxin B ointment <br /> ❑ PABA ❑ Metal(s) <br /> ❑ Foods: <br /> Other allergies: <br /> Reaction: <br /> EYES/EYEBROWS: Check all of the following that apply. <br /> ❑ Contact lenses ❑ Dry eyes ❑ Eye makeup sensitivities ❑ Blurred Vision <br /> ❑ Glaucoma ❑ Lasik/eye surgery ❑ Thyroid abnormalities ❑ Alopecia Areata(local) <br /> ❑ Alopecia Universalis(total) ❑ Pull out lashes/eyebrow compulsively(Trichotillomania) <br /> ❑ Other hair loss(describe): <br /> ❑ Eyebrow/Lash tinting ❑ Botox <br /> Date of last service: Date of last service: <br /> Other eye disorders: <br /> LITS: Check all of the following that apply. <br /> ❑ Cold sores/fever blisters/herpes.If yes, 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 />