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CLIENT INFORMATION SHEET <br />_Date of Birth: <br />ADDRESS <br />%fay ree contact you at this number if necessary? yes No <br />E1'EBR01�` PROCEDURES DESIRED: Vlicroblading �ObP <br />mrz onder Combo <br />_ 0 Hybrid <br />Horn did you hear about my scrcicc L_j Instagram ❑Facebook ❑Internet Website <br />❑Referred by Family!Friend (?game of referral: <br />Are you cu rently under the care of a physician'? ❑yes ❑ No <br />If yes, rchy'? <br />Physician's name: <br />Do you take antibiotics prior r6 surgery or dental procedures'? �'es No <br />If Yes, Why? _ -- - <br />Du you suffer ftom: Allergies to Latex ❑Allargic reactions to Antibiotics Hepatitis <br />[—]Moles or freckle at site of tattoo Heart problems or Carditrc calve disease <br />❑Hemophilia or other bleeding disorders F -I <br />lliabetes ❑Skin Problems <br />❑ Scarring (Keloids) ❑Eye Problems ❑ Epilepsy ❑Herpes infection at site of tattoo <br />Other risk factors for bloodbome pathogens (if none, indicate N''' ) <br />Are you presently taking any medication w <br />hich thins the blood? ❑_Yes ❑ \'o <br />r <br />[f yes, please explain: <br />Are you taking other medication;? ❑yes ❑ No <br />Are you pregnant or nursing? ❑ Yes ❑ No <br />Do you wear contact lenses? ❑ yes ❑ No <br />I unders <br />tand that my deposit of S is XO\' -Refundable. My deposit mill be applied Wwards my total price. If I cancel my <br />appointment, my deposit is forfeited Reschedules require 48hrs prior <br />o reschedulenotice, otherwise there kilt bz an additional charge of S <br />tmy appointment. <br />*Signed: (Client) Date: <br />