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CLIENT INFORMATION SHEET <br /> NAME Date of Birth: <br /> ADDRESS <br /> PHONE(Day) Night_ <br /> May we contact you at these numbers if necessary? Elyes E]No <br /> EYEBROW PROCEDURES DESIRED: 0 Microblading El Manual Shading <br /> How did you hear about my service? ElInstagrarn ❑Facebook ❑Internet/Website <br /> ❑Referred by Family/Friend(Name of referral: <br /> Are you currently under the care of a physician? FlYes ®No <br /> If so,why? <br /> Physician's name: <br /> Do you take antibiotics prior to surgery or dental procedures? ❑Yes []No <br /> If Yes, Why? <br /> Do you suffer from: ❑Allergies to Latex Allergic reactions to Antibiotics ® Hepatitis <br /> ❑Moles or freckles at site of tattoo [:]Heart problems or Cardiac valve disease <br /> ❑Hemophilia or other bleeding disorders [:]Diabetes ❑Skin Problems <br /> ❑Scarring(Keloids) ❑Eye Problems 0 Epilepsy ❑Herpes infection at site of tattoo <br /> Other: Please explain: <br /> Are you presently taking any medication which thins the blood? ®Yes ElNo <br /> Are you taking other medications? ❑Yes E]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 />