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Fawn Yee's Permanent Cosmetics <br /> 16231 Pacific Ave Suite 3,Stockton,CA 95207 <br /> (2 09)478-2266 <br /> sultation <br /> Date <br /> Quotation <br /> Service <br /> NAME TELEPHONE AGE REF <br /> ADRESS CITY <br /> 21P CODE OCCUPATION <br /> PER. AL H15TORY 6na OF TR TMENT <br /> Under eyeliner, Upper eyeliners,, <br /> Do you have sensitive eyes? —Yes _No Eyebrows Lips_ Other, <br /> Do you have allergies? —Yes —No <br /> If Yes,explain <br /> Black,„ Red Brown— Dark Brown— <br /> Mixed— <br /> rown®Mixed® Light Browne„ 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) <br /> Does your skin swell very easily? Yes No Eyebrows <br /> Have you had surgery around the eye(s)? Eyeliner <br /> —Yes _No Upliner <br /> Do you bruise easily? —Yes No Other <br /> WAIMER A§REEMENTICONTR60 <br /> The UNDERSIGNED acknowledges that FAWN YEE'S PERMANENT COSMETICS has explained the nature of <br /> all of theabove-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 1,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 /> 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 />