Brow Lamination & Lash Lift Waiver

1

Jamee Mittell Esthetics Studio believes that clients have the right to be informed of each treatment and to make an informed decision to proceed with a treatment. Brow Lamination and Lash Lift, as with many cosmetic procedures do have risks, although they are very rare, they are a possibility.

Brow Lamination and Lash Lift is a process of manipulating the brow or eyelash hairs to keep them in a desired shape. Tint is an optional service but is included unless otherwise discussed. Results last approx 4-8 weeks based on skin/hair type. The minimum or maximum duration from the procedure cannot be determined with certainty. As part of the aftercare, apply a moisturizing product developed specifically for Brow Lamination and Lash Lift daily to prolong the results. The brows and lashes must also not be exposed to heat or steam for 48 hours post procedure. If the brows or lashes are exposed to heat or steam before 48 hours has passed, the results may not last or damage to the hairs may occur.

I, the undersigned, consent to have my natural eyebrows and/or lashes laminated /permed (the Service) by Jamee Mittell Esthetics Studio and his/her/its staff assistants, contractors and employees (collectively herein, the Service Provider The Service and its associated risks have been or will be explained to me by the Service Provider in terms that I understand. The explanation includes:

The benefits of the Service; The nature of the Service and how the Service will be performed; The types of materials and products used during the Service; The most frequently occurring risks of the Service, and those risks which are unlikely to occur but which may involve serious consequences, including but not limited to the risk of experiencing: (a) Blepharitis and its associated symptoms, (b) an allergic reactions to the perming cream used to perm my natural eyelashes, (c) Traction Alopecia and its associated symptoms; (d) an eye injury due to perming cream falling on or into the eye; and (e) an eye or other injury occurring during the performance of the Service; How to properly care for my eyebrows that were permed; and How often I should expect to need to repeat the Service and the best methods for caring for my eyebrows.

2

Name* This field is required.

First Name

Last Name

3

I understand that if I receive brow lamination or a lash lift while pregnant or nursing, there could be unpredictable results due to the amount of hormones in my body.* This field is required.

I understand

4

I understand that if I am pregnant or nursing, getting any chemical treatment to my eyelashes, eyebrows or face is at my own risk and I should clarify with my doctor about the safety of these procedures before booking.* This field is required.

I understand

5

I understand and certify that I am 18 years of age or older.* This field is required.

I understand

6

Have you ever had facial waxing?* This field is required.

Yes

No

7

Have you ever had a lash lift?* This field is required.

Yes

No

8

Have you ever had brow lamination?* This field is required.

Yes

No

9

Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours?* This field is required.

Yes

No

10

Are you using Retinol, Retin-a, Renova or Accutane (an oral form of Retin-a)?* This field is required.If YES, please list product and the date of last use in "Other" section. Retinol should be discontinued for 14 days prior to wax

Yes

No

Other

11

Are you using any other skin thinning products and/or drugs?* This field is required.If YES, please list product and the date of last use in "Other" section.

Yes

No

Other

12

Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?* This field is required.

Yes

No

13

Do you use a tanning bed?* This field is required.

Yes

No

14

Are you diabetic?* This field is required.

Yes

No

15

Are you currently taking medications? If so, please list all (including over the counter drugs/herbal supplements).

16

Have you ever had any adverse reactions to tint or dyes on the eyebrows/face or scalp?* This field is required.

Yes

No

17

Have you ever had any adverse reactions to wax on the eyebrows/face or body?* This field is required.

Yes

No

18

I have read the above information and if I have any concerns, I will address these with my skin therapist. I give permission to my therapist to perform the requested procedure and will hold her and her staff harmless from any liability that may result from this treatment. I have given an accurate account of the questions asked above including all known allergies or 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. I am willing to follow recommendations made by my esthetician for a home care regimen that can minimize or eliminate possible negative reactions. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post- treatment care, 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, nor Jamee Mittell Esthetics Studio 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.* This field is required.

Clear

19

Photo Release By signing my name at the end of this paragraph, I grant Jamee Mittell Esthetics Studio permission to reproduce, publish, distribute or otherwise use in any reasonable manner my name, photograph, likeness and statements, including, but not limited to, before and after pictures of my eyes and eyelashes in connection with the promotion of the Service or the products used in the Service (or other similar services and products) in all media, including without limitation, the internet, news articles, advertisements, or other electronic or printed materials.

Clear

20

I was given or will be given the opportunity to ask the Service Provider any questions I have regarding the Service and I have had those questions answered to my satisfaction. Based on the foregoing, I hereby assume all of the risks associated with the Service, whether known or unknown, including, but not limited to, the risk of personal injury or property damage. As consideration for Service Provider performing the Service, I forever release Service Provider and his/her/its respective directors, officers, members, managers, employees, agents, contractors, attorneys, representatives, successors and assigns from any and all actions, claims, or demands that I, my assignees, heirs, next of kin, spouse, personal representatives and legal representatives now have, or may have in the future, for injury, death, or property damage, in any way related to the Service.* This field is required.

Clear

21

I understand that if I receive brow lamination or a lash lift while pregnant or nursing, there could be unpredictable results due to the amount of hormones in my body.* This field is required.

I understand

22

* This field is required.

I understand

23

* This field is required.

I understand

24

I understand that if I am breastfeeding, getting any chemical treatment to my eyelashes, eyebrows or face is at my own risk and I should clarify with my doctor about the safety of these procedures before booking.* This field is required.

I understand

25

I understand and certify that I am 18 years of age or older.* This field is required.

I understand

26

Have you ever had facial waxing?* This field is required.

Yes

No

27

Have you ever had a lash lift?* This field is required.

Yes

No

28

Have you ever had brow lamination?* This field is required.

Yes

No

29

Have you ever had any adverse reactions to waxing?

Yes

No

30

Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours?* This field is required.

Yes

No

31

If YES to previous question, please list product and the date of last use. Retinol should be discontinued for 14 days prior to wax.

32

If YES to previous question, explain below.

33

Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?* This field is required.

Yes

No

34

Do you use a tanning bed?* This field is required.

Yes

No

35

Are you diabetic?* This field is required.

Yes

No

36

Have you ever had any adverse reactions to tint or dyes on the eyebrows/face or scalp?* This field is required.

Yes

No

37

Have you ever had any adverse reactions to wax on the eyebrows/face or body?* This field is required.

Yes

No