Saline Tattoo Removal Consent Form
Please be advised that I am obligated to perform procedures in strict compliance with all hygiene and health protection measures. This information is confidential and it shall also be handled in that way.
Practitioner:
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Daisy Delgado
Kate De Hoyos
Today's Date
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Year
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Month
Day
Date
Name
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First Name
Last Name
Email
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example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Date of Birth
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Year
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Month
Day
Date
COVID-19 Client Screening
In order to ensure the health and safety of our staff and clients, please answer the following questions truthfully and to the best of your knowledge. Your responses will be kept confidential.
Health Questionnaire
Please understand that this treatment is not for everyone. In order to find out if you are fit for this procedure, please answer the following health questions truthfully. Gradelare Brows will assume no liability in the event you give false information to obtain the treatment.
Check the box if the following apply to you:
Please list any medical conditions, issues, or medications not listed above:
Terms & Conditions
*
Signature
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Please submit a picture of your ID/Passport:
Should be Empty: