INFORMATION SHEET Your face deserves the best quality! Your inscription Name:* First name Last name E-mail:. AddressCityProvincePostal / Zip CodeI was referred by : Name Other Date of birth:01020304050607080910111213141516171819202122232425262728293031 / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember / 2010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920DayMonthYearPersonal HistoryDo you ...*YesNoHave sensitive eyes?Wear contact lenses?Suffer from glaucoma?Have watery eyes?Swell easily?Bruise easily?Have a pacemaker?Do you suffer from...*YesNoHeart disease?Low blood pressure? High blood pressure?Mitral valve prolapse?Herpes (cold sores)?Hepatitis?Diabetes?HIV?Have you had an eye operation?*YesNoIf yes, please explain.Do you take medication?*YesNoIf yes, please list. Do you freeze easily at the dentist?*YesNoIf no, please explain.Do you have any physical disabilities?*YesNoIf yes, please explainDo you suffer from allergies?*YesNoIf yes, please list.Do you have any permanent makeup or tattoos?*YesNoIf yes, since when and where?Service(s):*EyebrowsLips Eyes ConcealerHairotherClinic:Select a valueSt-BrunoTrois-RivièresSherbrookeLavalI filled in the form: Name* to the best of my knowledge on:*01020304050607080910111213141516171819202122232425262728293031 / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember / 202120202019DayMonthYearSubmitReset