INFORMATION SHEET

maquillage permanent Josée Lemieux et Caroline Rochon

Your face deserves the best quality!

Your inscription

Name:*
E-mail:
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I was referred by :
Date of birth:
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Personal History

Do you ...*
Do you suffer from...*
Have you had an eye operation?*
If yes, please explain.
Do you take medication?*
If yes, please list.
Do you freeze easily at the dentist?*
If no, please explain.
Do you have any physical disabilities?*
If yes, please explain
Do you suffer from allergies?*
If yes, please list.
Do you have any permanent makeup or tattoos?*
If yes, since when and where?
Service(s):*
Clinic:
I filled in the form: Name*
to the best of my knowledge on:*
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