BEAUTY KULTURE STUDIO & ACADEMY
LASH LIFT & TINT CONSENT FORM
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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-
Area Code
Phone Number
Have you ever used hair color before?
*
Yes
No
Have you ever had an allergic reaction to hair color?
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Yes
No
Do you wear contacts?
*
Yes
No
Please list all over the counter or prescription skin care products you are currently using?
*
Please select any of the following conditions that apply at this time:
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Diabetes
Lupus
Any Auto-Immune Disease
NONE OF THE ABOVE
If you selected any of the above conditions, please describe below:
Please list any illnesses or conditions you are currently being treated by a physician for:
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Please list any medications you are currently taking, including but not limited to over the counter, herbs, vitamins, and/or supplements:
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Please list any allergies you have:
*
Have you ever had your brows or lashes tinted in the past?
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Yes
No
If you have had an adverse reaction to a previous tinting, please explain:
Although every precaution will be made to ensure your safety and well being before, during and after your tinting experience, please be aware of the possible risks below. By checking each field you have read and understand each statement and agree to continue with service:
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I understand that tinting lashes or brows has some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging or burning, blurry vision and potentially blindness should the tint enter into the eye.
I understand that if the tinting agent, developer, or mixture of both accidentally comes into contact with my eye, my eye will be flushed with water and medical attention may be required.
I understand that some irritation, itching, or burning may occur to the skin which comes in contact with the tinting agent.
I understand that there may be some residual dark staining left on the skin following the tinting process of either my lashes, brows, or both. This will fade and go away within a short time.
I understand that while every attempt will be made to provide me with my chosen color, everyones' hair absorbs color differently and my final results may not be the color I initially wanted.
I understand that over the course of several weeks, the tint will gradually lighten and fade. Re-tinting will be required to keep the new color fresh. Most clients need to re-tint every 3-4 weeks.
I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. In the event that I may have additional questions or concerns regarding my treatment, I will consult my esthetician immediately.
I have accurately answered the questions above, including all known allergies, prescription drugs and/or any products I am currently ingesting or using topically.
I have read the above information. By typing my full name in the box below I agree that If I have any concerns, I will address them with my skin care esthetician. Additionally, I hereby give my permission to my esthetician to perform the tinting procedure we have discussed and will hold him/her and his/her staff harmless from any liability that may result from this treatment.
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By typing my full name in the box below, I agree that this form constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I hereby agree that I understand the procedure and accept the risks. I am willingly agreeing to my discusses procedure and do not hold my esthetician responsible for any of my conditions that were present, but not disclosed in this form, which may be affected by the treatment preformed.
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Signature
SUBMIT
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