The Beauty Room: Brow & Tint Lamination Consent Form

Brow Lamination & Tint

Consent Form
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Email *
example@example.com
Address *

Street Address

City State

Zip Code
Please click any of the following that apply:

Positive reaction to a patch or sensitivity test Previous reaction experienced to the same or similar service in the past Skin conditions such as: Eczema, Dernatitis, Psoriasis, Lesions or Sores, Open Wounds Contagious Skin Diseases (Herpes Simplex, Chicken Pox, or Shingles) Skin Trauma, Cuts, Abrasions, Burns and Swelling in the immediate area Infections such as Impetigo or Conjunctivitis Chemotherapy Recent operations around eyes, head or face or scar tissue in immediate areas Hypersensitive Skin/Eyes Alopecia Trichotillomania Any disease/disorder that causes shaking, twitching or erratic movements Steroid or cortizone creams. Please provide medical clearance from dermatologist or doctor Brow growth serum Spray tans or self-tanning lotions Very dry skin Pregnant or lactating Contraceptive pill or HRT Post Chemotherapy. Please provide medical clearance from your doctor Currently Sunburnt
Did you have a recent Microblading or Tattoo service?Yes   No*
If yes, how long ago?

Did you have a recent Brow Henna application?Yes   No*
If yes, how long ago?

Did you recently receive a Botox or Dermal Filler?Yes   No*
If yes, how long ago?

Are you on any anti-ance medications such as Roaccutane, doxycycline and Epiduo gel etc?    Yes   No*
If yes, please explain what you are taking:

Are you on any anti-ance creams Vitamin A, Retinols, AHA's and BHA's?Yes   No*
If yes, please explain what you are taking:

Have you had Lash or brow tinting, lash lifting, lash perming, eyelash extension or semi-permanent mascara applied previously? Yes   No*
Agreement

I request and consent to these procedures being carried out today without undergoing a sensitivity patch test. The sensitivity test, which if conducted may indicate my sensitivity/allergy to the products. I under he contents of this form and take full responsiblity for my actions, thus absolving all other parties of their responsibilites, if any, associated with the supply of the products and services(s).
Signature *

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Date *

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Date
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Brow Lamination & Tint