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Brows By Michelle Grace PRO545320 <br /> 37 W Yokuts Ave. Suite#B8, Stockton CA, 95207 <br /> March 27, 2025 <br /> Photo 10: Client did not fill out "Are you currently taking any medication which thin the blood?" <br /> CL=N HW0RMAn0N sE[MT <br /> NAME V <br /> Date of Birtb:A_42,�4=4 <br /> ADDRESS �P f <br /> PHONE <br /> May we comact you aL ibis number it—slimy? Yes DNo <br /> EYBEROW PROCEDURES DESIRED:[3Mimnbl�ing we Powdar COLobo HYbrid <br /> Slow did you hear about my service? Djmtagram OFWebook Dintemet/Webmte <br /> [�{]ReEef,�ea by�ar�ily�riend cNm.te ofrzr rfa<: \IrA y1PSS�f l <br /> ALe you ccnaently under the care of a Lysician? {/�Ies ❑No <br /> if yes,why'' - <br /> 1 <br /> pbysla-Cs <br /> Da you Lake andbiotits Ptiar to surgery or dental plvicedlaes? [Dyes L1No <br /> If Yes.Why? <br /> f�O ymr syg fiouU�Allergses Lo Latex[]P-llergic TCariieRs to ANllbaooGs []EiepaLili' <br /> �Mol®or fie tiles L>t site of tattoo Ql3,e�a-r(L pLaUlems ar Cardiac valve disease <br /> �llemoplsilia o<o�her bleeding disorders t�Diabetss []Skm Problems <br /> Q Scarring(Keloids) DRYe <br /> Problems []BQilepsy Qllmpes infection at site of lauao <br /> Odler risk faetrns Eor bkocdbarae patlLo�rls(LtLLeot.i <br /> Are You rti se rly taking any medi®Lion wbicb Lbins the blood? r_LYes ❑No <br /> lfyes,Pl--plaice: <br /> AR yov 1,king oLber medirntioes? Y_ [] No <br /> Are You <br /> ant or nursing° Q Yes No <br /> pregn <br /> Do Yau wear cvntacL lenses:' 0 Yes [ No <br /> 1 vnderslav'L lha dep°°i[a,_O Is NON-He &blc MY dill s1L..rill k oPhlicd LoavNz mY laty yi�t.if I .1 m <br /> z. N Y <br /> de I is f - RescLLtdnlcs rtgaLre 981ns pfior oolia,oLlxnrise Uh will <br /> 11 Ix w additivnel choLae of S <br /> 6o reset M L°Y <br /> {Client) Qele: �1 <br /> .signed— <br /> Alexander Cruz, EHS 10 <br />