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ABOUT
SERVICES
TRAINING
CLIENT FORMS
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CONTACT US
INTAKE CONSENT FORMS
CLIENT INFO
Name
*
Email
*
Date of Birth:
Month
Month
Day
Year
Address:
Apt. #:
City:
State:
Zip Code:
Cell Phone:
Home Phone:
Occupation:
Emergency Contact Information:
Name:
Phone
How did you hear about us?
Procedure(s) desired:
Brows
Eyeliner
Lips
Camouflage
Areola Complex
Correction
LIST ALL MEDICATIONS YOU ARE PRESENTLY TAKING
1. Name of Drug
1. mg o mcg
1. Amount/Day
1. Why it was prescribed to you?
No medication in the last 6 month
LIST OF ALL MEDICATIONS YOU TOOK IN THE LAST SIX MONTHS THAT YOU ARE NO LONGER TAKING
I. Name of Drug
I. mg o mcg
I. Amount/Day
I. Why it was prescribed to you?
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