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. Hair Discovery <br /> Consultation . <br /> Date <br /> Quotation <br /> Advanced Esthetics Service <br /> 5756 Pacific Ave. #11 <br /> Stockton, CA 95207 <br /> (209)478-2216 ' <br /> NAME TELEPHONE. AGE• R'EF <br /> ADDRESS CITY <br /> ZIP CODE OCCUPATION <br /> PERSONAL HISTORY AREA OF TREATMENT <br /> Do you have sensitive eyes? ❑ Yes ❑ No Under Eyeliner Upper Eyeliner <br /> Do you have Allergies? ❑ Yes ❑ No Eyebrows Lips Other <br /> If Yes, Explain <br /> COLOR <br /> Do you have Glaucoma? ❑ Yes ❑ No Black_ Red Brown_ Dark Brown_ <br /> Do your eyes water easily? ❑ Yes ❑ No Mixed_ Light Brown_ Grey_ <br /> Do you wear contact lenses? ❑ Yes ❑ No Persian Blue_ Light Blue_ Blue/Black- <br /> (If yes,please remove before treatment Mixed Lip Color <br /> Does you skin swell very easily? ❑ Yes ❑ No <br /> Have you had surgery around SHAPE <br /> the Eye(s)? ❑ Yes ❑ No <br /> Do you bruise easily? ❑ Yes ❑ No Charges <br /> Eyebrows Cash Terms <br /> Eyeliner Cash Terns <br /> Lipliner Cash Terms <br /> Other Cash Terms <br /> WAIVER AGREEMENT/CONTRACT <br /> THE UNDERSIGNED acknowledges that ADVANCED ESTHETICS has explained the nature of <br /> all of the above-noted treatment including the risks and dangers inherent therein. <br /> 1 HEREBY CONSENT to ADVANCED ESTHETICS performing the above-noted treatment <br /> procedures on me and in consideration of their so doing,I hereby release and forever discharge <br /> ADVANCED ESTHETICS, its officers and employees of and from all claims,demands, damages,actions <br /> or causes of action arising out of the performance of the said treatment procedures,which I,my heirs, <br /> executors,administrators or assigns can, shall, or may have. (NO REFUND ON ANY TREATMENT.) <br /> I accept the above color,design and payment terms in this contract. <br /> TREATMENT REQUIREMENTS: <br /> EYEBROWS-The cost covers 2 visits within 90 days, all other visits a fee of S will be charged. <br /> EYELINERS -The cost cover 2 visits within 90 days, all other visits a fee of S will be charged. <br /> LIPLINING-The cost covers 2 visits within 90 days, all other visits a fee of$ will be charged. <br /> Signature Date Witness Date <br />