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Brows By Michelle Grace PR0545320 <br /> 37 W Yokuts Ave. Suite#B8, Stockton CA, 95207 <br /> March 27, 2025 <br /> Photo 9: Client consent form, checked yes for medication that thins blood, but no explanation given. <br /> 11 CLIEhPT�gogMA'TION SIMET <br /> f NAME Date of Bird,, J <br /> ADDRESS (-��f'1 <br /> YIIONE <br /> Keay a contact you at this number if necessary° [✓�Y� Q No <br /> EYEBROW PROCEDLMES0ESIR->=D-©Microhlading m6>z Pawdec Combo QHybrid <br /> liow did you hear about my service? Ohestagram E]Fa5ceabook IlIntemetlWebshe <br /> Referred by F'arailylFriend(Name of referral- tn/A 1f,'� <br /> Am you currently under the care of a physician? ❑Yes <br /> Qw— <br /> If yes,why? - <br /> Physicasn's name: <br /> Do You take antibiotics prior to surgery or dental procedures? nYes h:;Jo <br /> If Yes_Why? <br /> Do you suffer from:©Allergi,to Ietex DAOergic reactions to Antibioucs G hepatitis <br /> 0 Mohes or freckles at site of tattoo i7iHearturubleuis or Cardiac valve disea- <br /> El Hemophilia or other bleeding dlsord9ers ODiabetes ©Skirt Problems <br /> El Scarring(Icelaids) DEye Problems Q Hpdepay ©Herpes i�nf)ection at silt of tattoo <br /> Other risk factors for bloodborne pathogens(if none,indkmLe NrA) <br /> Arc you presently taking any medication which thins the blood? Ldt es �]No <br /> if Yes-please explain' <br /> Are You taking other medications? ❑ Yes dNo <br /> Are you pregnant or nursing? ❑ Yes Lf N. <br /> Do you wear contact lenses? [�S(es ❑ No <br /> t underxeutd row my depos(t of S is NON-Ref M <br /> xppointmear,my deposit is foriei[ed.Reschtedulrs re of d'b)& Y d posit will be applied towards my total per-If i catecel m <br /> to reschednte toY appoiwateaL 4 Prior nodice.atherwlse ehce wdI be an adefitioael charge of 5 <br /> Signed-— �� <br /> _ (Client) Date: ✓7 <br /> Alexander Cruz, EHS 9 <br />