Brow Consent For Treatment

Mode Beauty NYC

Brow Consent Form
Name*
Phone *
Birthdate*

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
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How did you hear about Mode Beauty NYC?
Have you ever had a reaction to brow/lash tint or hair dye? *

YesNo
Do you wear contacts? *

YesNo
Are you using any over-the-counter or prescription skin care products*

YesNo
If yes, please list
Are you taking any medications or supplements?*

YesNo
If yes, please list
When was your last sun exposure, including tanning beds? *
Do you use sunless tanning products? *

YesNo
If yes when was the last time you applied?
Consent for 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 esthetician 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 esthetician 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 esthetician, whose signature appears below, 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.
Intial Here*
I acknowledge that I must adhere to Mode Beauty NYC’s cancellation and late policies. I understand that appointments should be canceled with at least 24 hours notice to allow availability for other clients.

I also understand that if I arrive more than 10 minutes late, my appointment may need to be adjusted, rescheduled, or canceled based on the remaining time available.
Initial Here*
At Mode Beauty NYC, your satisfaction is my top priority. If, for any reason, you’re not fully satisfied with your service or product, I kindly ask that you adhere to the following guidelines:

If you have any concerns about a service or product, please reach out to me directly within 24 hours of your appointment or purchase.

Before posting a review or sharing your concerns on social media, I kindly request that you allow me the opportunity to address and resolve the issue. My goal is to ensure you leave feeling confident and cared for.

If necessary, I may request that you come in for an in-person assessment. This will allow me to better understand your concerns and determine the best course of action to address them.

Please note that all services and packages are non-refundable. However, I am committed to doing everything possible to make your experience positive and meet your expectations.

Exchanges for products may be available within 24 hours of purchase at my discretion. Please provide details about your concerns to help me better understand how to assist you.

By initialing here, I acknowledge and agree to these terms
Initial Here*
Signature

Clear
Date*

MonthDayYear
Signature Of Parent or Guardian If Under Age 18

Clear
Should be Empty:

Mode Beauty NYC

Consent for Treatment