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City : State : Zip : <br /> Home Phone : Work Phone : <br /> Referred By : <br /> Fees Discussed : <br /> Additional Fee : <br /> Procedure Requested : <br /> Areas of Concern : <br /> Technician Name : <br /> Pigment(s) Used : <br /> Lot # and Batch # : <br /> Expiration Date (s) : <br /> Machine (s) Needle (s) Used : <br /> Anesthetic Used : <br /> Touch - up (s) Done On : <br /> Additional Procedures : <br /> Infection , Adverse Reaction , Allergic Reaction Incident Report <br /> 7 <br />