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10 <br /> MICROBLADING <br /> CLIENT INFORMATION AND HISTORY <br /> 71 <br /> 4PFOINTMENT DATE APPOINTMENTTIME <br /> (PLEASE PRINT) <br /> CLIENT INFORMATION <br /> FULL NAME <br /> BIR-HDATE PHONE NUMBER <br /> ADDRESS <br /> ZIP CODE CITY STATE / PROVINCE <br /> EPv1,A.ILADDRESS <br /> EMERGENCY CONTACT <br /> Ever had a microblading or cosmetic tattoo Y/ N <br /> procedure done in the past? <br /> If yes. when was the last procedure? <br /> Dc ycu have moles/ raised areas on or around Y/ N <br /> your eyebrows? <br /> Ever had eyebrow hairtransplant? Y/ N <br /> ;rrently have or ever had piercings on eyebrows? Y/ N <br /> Please list any medications you are currently taking: <br /> Copyright©ALashBoutique <br />