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Fawn Yee's Permanent Cosmetics <br /> 6231 Pacific Ave Suite 3, Stockton, CA 95207 <br /> (209)478-1266 <br /> Consultation <br /> Date <br /> Quotation <br /> Service <br /> NAME TELEPHONE AGE REF <br /> ADRESS CITY <br /> ZIP CODE OCCUPATION <br /> PERSONAL HISTORY AREA OF TREATMENT <br /> Under eyeliner_ Upper eyeliner_ <br /> Do you have sensitive eyes? _Yes _No Eyebrows_ Lips_ Other_ <br /> Do you have allergies? _Yes _No <br /> If Yes,explain COLOR <br /> Black_ Red Brown_ Dark Brown— <br /> Mixed— <br /> rown_Mixed_ Light Brown_ Grey_ <br /> Do you have glaucoma? _Yes _No Persian Blue_ Light Blue_ Blue/Black- <br /> Do your eyes water easily? _Yes _No Mixed_Lip Color <br /> Do you wear contact lenses? _Yes _No <br /> (if Yes,remove before treatment) Charges <br /> Does your skin swell very easily? _Yes _No Eyebrows <br /> Have you had surgery around the eye(s)? Eyeliner <br /> _Yes _No Lipliner <br /> Do you bruise easily? _Yes _No Other <br /> WAIVER AGREEMENT/CONTRACT <br /> The UNDERSIGNED acknowledges that FAWN YEE'S PERMANENT COSMETICS has explained the nature of <br /> all of the above-noted treatment including the risks and dangers inherent therein. <br /> I HEREBY CONSENT to FAWN YEE'S PERMANENT COSMETICS performing the above-noted treatment <br /> procedures on me and in consideration of their so doing, I hereby release and forever discharge FAWN YEE'S <br /> PERMANENT COSMETICS, its officers and employees of and from all claims,demands,damages,actions or causes <br /> of action arising out of the performance of the said treatment procedures,which I, my heirs,executors, <br /> administrators or assigns can,shall,or may have.(NO REFUND ON ANY TREATMENT) <br /> I understand there may be temporary minor bleeding, bruising,swelling and redness and that a healing <br /> period is normal and expected. I will follow aftercare instructions given to me at the end of the procedure. I <br /> understand this body art procedure is permanent. <br /> I accept the above color,design and payment terms in this contract. <br /> TREATMENT REQUESTS: <br /> EYEBROWS–The cost covers 2 visits within 90 days,all other visits a fee of$ will be charged. <br /> EYELINERS–The cost covers 2 visits within 90 days,all other visits a fee of$ will be charged. <br /> LIPLINING–The cost cover 2 visits within 90 days,all other visits a fee of$ will be charged. <br /> Signature Date Witness Date <br /> 91�CC . 2i, <br />