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8
Questions
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1
Full Name
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2
Which Eyetreatment are we patch testing?
Brow tint
Lash lift
lash tint
Brow lamination
Eyelash extension
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3
Do you have any allergies? (Please specify)
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4
Do you have/have you had any of the following:
Skin condition around the eye area.
Lack of sensitivity around the eye.
Epilepsy
Eczema
Styes
Cysts in eye area
Dry eye syndrome
Hayfever
Dermatitis
Pregant
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5
Patch test completed?
YES
NO
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6
Disclaimer
Signing this disclaimer you have agreed and happy to go forward with the treatment without a patch test. If anything may happen you are responsible for that cause or effects to that treatment. Please sign yes if you are happy with the above without a patch test.
YES
NO
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7
Date
-
Date
Year
Month
Day
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8
Signature
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