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4 <br /> D <br /> CLIENT INFORMATION SHEET <br /> NAME Date of Birth: <br /> ADDRESS <br /> PHONE (Day) Night <br /> May we contact you at these numbers if necessary? ❑Yes ❑No <br /> PROCEDURES DESIRED: <br /> ❑Eyeliner ❑Eyebrows ❑Lipline RFull Lip Color ❑Nipples <br /> ❑Beauty Mark []Skin Repigmentation ❑Other <br /> If you selected "other"please explain: <br /> Have you ever had a cold sore? ❑Yes [:]No If yes, you must contact your <br /> physician for a prescription of ZOVIRAX capsules, an antibiotic which prevents cold sores. <br /> I have read the above information regarding ZOVIRAX and understand its use is mandatory <br /> if I desire lipline or full lip color procedures. <br /> *Signed: (Client) <br /> Who referred you: <br /> Are you currently under the care of a physician? ❑Yes ❑No <br /> If so, why? <br /> Physician's name: <br /> Do you take antibiotics when going to the dentist? ❑Yes ❑No If Yes,Why? <br /> Do you suffer from: ❑Allergies ❑Moles or freckles at site of tattoo ❑Hepatitis <br /> ❑Heart Problems ❑Hemophilia ❑Diabetes ❑Skin Problems ❑Scarring(Keloids) <br /> ❑Eye Problems ❑Epilepsy ❑Other: Please explain: <br /> Are you presently taking any medication which thins the blood? ❑Yes ❑No <br /> Are you taking other medications? ❑Yes ❑No If yes, explain: <br /> Are you pregnant or nursing? ❑Yes ❑No <br /> Do you wear contact lenses? ❑Yes [:]No <br /> I understand that if I fail to cancel my appointment within 24 hours,there will be a charge of$ <br /> *Signed: (Client) Date: <br />