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The Piercing Beauty
Kansas City, MO
First and last name
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Mobile number
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Email address
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Emergency Contact:
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Emergency Contact's Phone number:
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Any recent surgery, including plastic surgery?
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required
Yes
No
If yes, please explain:
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Have you ever had irritation after using any skin care product?
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required
Yes
No
Have you ever had an allergic reaction to Latex
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required
Yes
No
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.
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required
Yes
I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received.
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required
Yes
I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history.
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required
Yes
I understand the treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.
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required
Yes