Lash and Brow Consultation

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityCounty

Post Code

Phone Number*

Area CodePhone Number

Email*

example@example.com

Date of Birth *

Date

Select treatment you are having(select multiple if applies)*

Have you had a patch test?*

YesNoPositiveNegative

Date of Patch test*

Date

Have you had Henna or Brow Stain treatment before?

YesNo

Have you had lashes/ brow tinting before?*

YesLashesBrowsNo

Have you had a lashlift before?

YesNo

Have you ever had a reaction to hair dye?*

YesNo

Contra Indications (please choose)*

Medical conditions *

Medication*

List any allergies *

I am age 16+*

YesNo

I’m aware that Henna/tint may stain the skin?*

YesNo

The technician has explained the procedure and after care properly?*

YesNo

I agree to contact Therabeautic immediately in the event of an adverse effect?*

YesNo

Although every precaution will be made to ensure your safety and well-being before, during and after your tinting/henna application, please be aware of the possible risks below.

I understand that tinting/henna 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 should the tint enter into the eye.

I understand that if the tinting/henna 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/henna agent.

I understand that there may be some residual dark staining left on the skin following the tinting/henna 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 colour, everyone’s hair absorbs colour differently and my final results may not be the colour I initially wanted.

I understand that over the course of several weeks, the tint will gradually lighten and fade. Re-tinting/henna will be required to keep the new colour fresh. Most clients visit every 3-4 weeks.

I have read the above information. If I have any concerns, I will address these with my skin care therapist. I give permission to my therapist to perform the tinting/henna procedure we have discussed and will hold her 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 aesthetician 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 aesthetician 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 aesthetician 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 have read and fully understand the risks and precautions of any lash and brow procedures?

yes

Date*

Date

Signature*