Brow Tint/Henna Consultation Form

Brow Tint/Henna Consultation Form
Name*

First NameLast Name
Email*
example@example.com
Birth Date

MonthDayYear
Best Contact #*

Area CodePhone Number
Current Conditions, Previous Discomfort, Stinging or Adverse Reactions (Please check all that apply)*

Inflammation of eyelid/eyebrow areaSkin Trauma swelling or abrasions,Recent operations around eye, head or face in immediate areaRecent tattooing, microblading or feather touch treatmentsPrevious reaction to Henna applicationChemotherapy (current cancer treatment)Eye infections/conjunctivitisRecent eye surgeryHypersensitive skinSunburnBotox/dermal fillersSkin Disorders/diseaseNONE OF THE ABOVE
Contraindications that restrict treatment*

FeverInfectious or contagious disease (including but not limed to HEP A/B/C and HIV)InflammationCutsSevere BruisingPsoriasisNail SeparationEczemaNONE OF THE ABOVE
Any medications:
Have you had lash or brow tinting before and experienced a reaction
Consent for treatment:

I give permission for Miss Melissa, LLC, dba The Nail and Wax Room, (and their associates) to treat me today. I have disclosed any allergies and current medical conditions. I release any liabilities that may arise during or after as a consequense of my treatment. If my treatments are ongoing, I will disclose any new allergies, medical conditions or medications at the time of my service.

If under 18, please have parent or guardian complete and sign.
Date of Appointment

MonthDayYear
Date
Today's Date*

MonthDayYear
Date
Signature*

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