Laserfiche WebLink
r CLIENT HISTORY <br /> Name Date of Birth <br /> Address <br /> Street City State Zip <br /> Home Phone Business Phone <br /> May we contact you at these numbers'? <br /> Referred b% <br /> Emergency Contact Phone Number <br /> Driver's License #r' Social Sec. # <br /> PROCEDURE(S) DESIRED: <br /> Upper eyeliner Partial eyebrows Lipliner Beauty Mark <br /> Lower eyeliner Full eyebrows Full lip color Scar Camouflage <br /> Other: <br /> ALLERGIES: Check if you have ever had an allergic reaction to any of the following and describe what happened below: <br /> Lanolin Latex rubber <br /> Bacitracin Ointment Neomycin or polymyxin B ointment <br /> Novocaine Lidocaine <br /> PABA Metals: <br /> Foods: <br /> Other allergies: <br /> Reaction: <br /> EYES/EYEBROWS: Check all of the following that apply: <br /> Contact lenses Eye makeup sensitivities <br /> Dry eyes Blurred vision <br /> Thyroid abnormalities Glaucoma <br /> ;Alopecia Universalis (total) Alopecia Areata(local) <br /> Other hair loss, describe: <br /> Pull out lashes or eyebrows compulsively(Trichotillomania) <br /> Evebrow tinting, date of last service: <br /> Other eve disorders: <br /> LIPS:Check all the following that apply: <br /> Cold sores.Tever blisters.1herpes around the mouth. If ves,a prescription for Zovirax;is required prior to any <br /> lip procedure. <br /> Collagen injections— location: <br /> Fat transfer injections—location: <br /> Gore-Tei implants—location: <br />