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Fawn Yee's Permanent Cosmetics <br /> 6231 Pacific Ave Suite 3,Stockton, CA 95207 <br /> (209)478-3266 <br /> Consultation <br /> Date <br /> Quotation <br /> Service <br /> NAME TELEPHONE AGE REF <br /> ADRESS CITY <br /> ZIP CODE OCCUPATION <br /> Note:Client MUST be at least 18 years of age to undergo any permanent makeup procedure. <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® 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? sYes —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 and that inks are not FDA approved and health consequences <br /> are unknown.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 />