Eye Brow and Eye Lash Tinting Consent Form

Name *

First Name Last Name

Date *

Date

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Email *

example@example.com

Phone Number *

Area Code Phone Number

Have you ever used hair color before? *

Yes No

Have you ever had an allergic reaction to hair color? *

Yes No

Do you wear contacts? *

Yes No

To help with the comfort of your eyes, your contacts may need to be removed during lash tinting.

Have you ever had your brows or lashes tinted? *

Yes No

List any known allergies: *

N/A if none.

If you 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 application, please be aware of the possible risks below:

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 medical attention may be required. *

Yes

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. *

Yes

I understand that some irritation, itching or burning may occur to the skin which comes in contact with the tinting agent. *

Yes

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. *

Yes

I understand that, while every attempt will be made to provide me with my chosen color, everyone’s hair absorbs color differently and my final results may not be the color I initially wanted. *

Yes

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 *

Yes

I have read the above information. If I have any concerns, I will address these with my technician. I give permission to my technician 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. I have accurately answered the questions above, including all known allergies, prescription drugs, or products I am currently ingesting or using topically. I understand my technician will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the technician immediately. I agree that this 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 understand the procedure and accept the risks. I do not hold the technician/salon responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.

I agree to terms & conditions *

Yes

24-hours notice is required for any canceled or rescheduled appointment or 50% of the service price will be charged. Failure to show without notice will require full payment of service booked. By signing below, I’m acknowledging that I am 18 years of age or older and have read and understand the terms of the cancellation policy. The Achery does not offer monetary refunds on services rendered. We do have a 7-day policy in place on services in which a client can come back and have corrections made. Fees may apply.

Signature *

Clear

Parents must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.

Parent/Guardian Signature:

Clear