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D z O <br /> X O <br /> 1 O rt n v <br /> Q_ CY) rD <br /> CD W Z3 N <br /> Ln <br /> O al <br /> Ln O <br /> N O D � <br /> 1010 Central Av Versailles Salon And Spa 0 m f a ,CA 95376 <br /> _ Salon 209 63(r15a5 Cell 209 275 9133 Q <br /> �' ,.me Address: )./ al <br /> ani � <br /> NnkSheet � ' (7 <br /> Work Addr D <br /> 05S• rlry se.ee zy C <br /> rD <br /> Nak5ent r+ <br /> Ln <br /> Home Phone: 65� �� r, s, Lri <br /> zip O W <br /> Work Phone: Z5 M <br /> Z3 J <br /> Employer. al <br /> Occupation: A Z l /J <br /> Are you now or have you,been under the care of a physician within the last two years? <br /> Yes' lease Y 0 <br /> I <br /> y P provide Physician's Name,address and hone number. O <br /> ,--F <br /> n <br /> Person to contact in an emergency: , ai/ O <br /> 3 <br /> c� <br /> rt <br /> h _- Addmlk Pbove No- rD <br /> Lest all medications you are currently taking,including Resin A,Glycolic Acid and Acutane: CL <br /> Have you been prescribed antibiotics prior to surgical or dental procedures: <br /> Have you recently undergone a skin peel? <br /> What products do you use for skin care? <br /> Are you pregnant or breastfeeding? <br /> Are you allergic to latex: Are you allergic to an antibiotics: <br /> Do you have or have you had an of the allowing candrhans(answC Corneal Abrasions <br /> Abnormal Heart Condition Eye Surgery ar tn" <br /> Cold Sores Ble harp las e&d surgery) <br /> Herpes Simplex at procedure site Visual Disturbances <br /> Hemophilia or other bleeding disorders Cancer <br /> High or Low Blood Pressure Cancer FGrowihs/Cysts <br /> Prolonged Bleeding Chemotherapy/IZadeation <br /> Circulatory Problems Are you pregnant? <br /> IStailbetes Hepatitis <br /> Fainting Spells/Dizziness Do you wear contact lenses? <br /> Do you use tobacco products? <br /> Glaucoma Cardiac Valve Disease? <br /> E e Eye Drops or Ocular Medications? <br /> history of hemophilia or other bleeding Hyper-pigmentation? <br /> disorders Curren fly to cing aspirin/ibuprofen? <br /> When was your last eye exam? <br /> Examining Physician:+jam 7_ <br /> JZZ <br /> Si.4stare Date <br /> C`Va \Ver-W-\Do enesl]essicaNArbok Desktap%ZO17 REVISEDConsenl Form TEMPLATE ERICAdo ReviIV5/2R16 Page 5 of 8 <br /> Ln <br /> O1 <br /> N <br /> Ol <br />