Brow Lamination and Tint Consent Form

Brow Lamination and Tint Consent Form
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date of Birth
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Upload a copy of your Photo ID/Driver's License/Passport

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Driver's License #
Driver's License State Issued
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship to Client*
Appointment Date*

MonthDayYear
Date
Contraindications/Disqualifications
- Recent brow lamination 6-8 weeks ago
- Sunburned eyebrows
- Henna tinted eye brows less than 10 weeks ago
- Recent eye surgery/laser/fillers/botox
- Recent chemical peels
- Blood thinners or severe health medications
- Sensitive skin
- Have a positive reaction to a patch test
- Have cuts, abrasions, inflammation, or swelling in the treatment area or who have experienced a positive reaction to the patch test
- Have alopecia, sunburn, very sensitive skin, or are under the influence of alcohol or drugs, psoriasis/eczema
- Have cancer or are undergoing chemotherapy or the recovery period
- Have had recent scar tissue, blemishes, wounds around the brow area
- Currently using retinoids & accutane
- Currently pregnant or breastfeeding
Pre-Care Instructions
- Do not trim your eyebrows before your brow lamination appointment
- Do not get your brows wet for 24 hours
- Avoid touching or sleeping on your eyebrows
- No chemical/physical exfoliants/acne skincare products for 3 days before and after your appointment (salicyclic acid, benzoyl peroxide, retinols, AHA/BHA)
- No aggressive combing/scrubbing the brows
- Moisturizeyour brows with the aftercare oil provided
- Comb your brows in place as often as needed especially when wet
- Let your technician know if you have concerns about your brows
- Reach out to your technician if you have any questions or concerns
YesNo
If you answered yes to the above question, have you ever had an adverse reaction? Please explain or mark N/A if not applicable.*
List the date of your last brow lamination

MonthDayYear
Date
YesNo
If you answered yes to the above question, please explain or mark N/A if not applicable.*
YesNo
If you answered yes to having your eyebrows microbladed or tattooed, please list the date you had your eyebrows tattooed?

MonthDayYear
Date
YesNo
List the date you last used skin care products around your brows with the above ingredients. If you did not use products with these ingredients, leave this field blank.

MonthDayYear
Date
YesNo
List the date you last had your brows bleached or tinted

MonthDayYear
Date
Upload a photo of your brows

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Medical History
YesNo
YesNo
If you answered yes to the above, please explain and list when you were last treated or N/A if non applicable.*
List any medications you are currently taking or N/A if non applicable.*
YesNo
Eczema Around the Eyes/Eyebrow AreaPsoriasis Around the Eyes/Eyebrow AreaRecent Eye SurgeryRecent Eye InfectionSensitive SkinSunburnAllergic to Cosmetic, Skincare Products, Makeup, Soap, ShampooCuts or Abrasions on the Treatment AreaWatery EyesInflammation or Swelling on the Treatment AreaRecent Scar TissueConjunctivitis/Styes/InfectionN/A
Do you have any medical conditions we should be aware of?*
Please list any illness or condition you are currently being treated by a physician for or N/A if non applicable.*
Although every precaution will be taken to ensure my safety and wellbeing before, during and after the brow lamination process I acknowledge that I am aware of the following information and possible risks by signing the below.*

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I am aware and understand that receiving a Brow lamination treatment can in some cases cause an allergic reaction.*
Initial Above
I understand that results may vary for everyone. Overall skin conditions and aftercare will ultimately affect the retention of Brow Lamination results.*
Initial Above
I fully understand that a reaction can occur at any time, even if I have received this service on previous occasions.*
Initial Above
I understand these risks and and if I have any concerns, I will seek guidance from my technician before my treatment.*
Initial Above
I understand that it is my responsibility to inform the technician if there are any reactions.*
Initial Above
Release of Liability: Client agrees to indemnify, hold harmless and release the service provider, its agents, employees, officers, directors, representatives, assigns, members, affiliated organizations, and insurers, and others acting on the Company's behalf, of all claims, demands, causes of action, and legal liability, whether the same be known or unknown, anticipated or unanticipated, and further agrees that except in the events of the Company's gross negligence or willful and wanton misconduct, no claims, demands, legal actions and causes of action, shall be made against the Company for any economic and non-economic losses of any kind.*
Initial Above
Reschedule/Cancelations: We require 72-hour advance notice to reschedule/cancel an appointment. One reschedule is allowed free of charge. All future rescheduled appointment require a brand new booking fee. Pre-payment in full is required to reschedule after 3 reschedules or more.*
Initial Above
All fees and services are non refundable.*
Initial Above
I acknowledge and give consent to Glow Beaute to use images of my tattoo(s) for marketing and, or publishing purposes in various media such as the internet, magazine, printed and or television etc.*
Initial Above
COVID-19 Liability Waiver

Please state whether you've experienced/are experiencing the following*

Rows	Yes	No
Fever
Cough
Shortness of Breath
Persistent Pain in the Chest

YesNo
YesNo
YesNo
YesNo
ONLY IF YOU ANSWERED YES ABOVE Contact tracing will be conducted for close contacts (any individual within 6 feet of an infected person for at least 15 minutes) of laboratory-confirmed or probable COVID-19 patients. Testing is recommended for all close contacts of confirmed or probable COVID-19 patients.Asymptomatic contacts testing negative should self-quarantine for 14 days from their last exposure (i.e., close encounter with confirmed or probable COVID-19 case) If you have already been tested negative after being in contact with someone positive, please provide your test results below.

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I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.I further acknowledge that Glow Beaute has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.I further acknowledge that Glow Beaute can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, salon staff, and other salon clients and their families.I voluntarily seek services provided by Glow Beaute and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.I attest that:* I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.* I have not traveled internationally within the last 14 days.* I have not traveled to a highly impacted area within the United States of America in the last 14 days.* I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.* I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities.* I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19. I hereby release and agree to hold Glow Beaute harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the salon, or that may otherwise arise in any way in connection with any services received from Glow Beaute. I understand that this release discharges Glow Beaute from any liability or claim that I, my heirs, or any personal representatives may have against the salon with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Glow Beaute. This liability waiver and release extends to the salon together with all owners, partners, and employees.*

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Client Signature Date*

MonthDayYear
Date
Should be Empty:

Brow Lamination and Tint Consent Form

Medical History

COVID-19 Liability Waiver