Brow_Wax_and_Tint_Consent

Brow Wax & Tint Intake Form
General Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone#*
Email*
example@example.com
Occupation
Emergency Contact Name
Phone#
How did you hear about us?

Brow Tint & waxing History
Have you ever had your brows or lashes tinted?*

YesNo
If yes, have you ever had an adverse reaction?*

YesNo
If yes, please explain:
Have you used hair color before?*

YesNo
Have you ever had an allergic reaction to hair color?*

YesNo
If yes, please explain:

Consents
I hereby consent to and authorize Lancaster’s Luxe Lashes to perform the following procedure:

I understand that this service may have certain side effects which may include but are not limited to skin removal, redness, swelling, and tenderness. I have had the opportunity to ask questions regarding these side effects and other possible complications. I give permission to my esthetician to perform the procedure listed above we have discussed and I will hold them and the spa harmless from any liability that may result from this treatment.

I have read and understood the aftercare home care instructions. I understand how important it is to follow all instructions given to me for aftercare. In the event that I may have additional questions or concerns regarding my treatment and suggested aftercare. I will consult the esthetician immediately.

I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies
or prescription drugs or products I am currently ingesting or using topically.

I hereby grant and authorize Lancaster’s Luxe Lashes the right to take, edit, alter, copy, exhibit. publish, distribute and make use of any and all pictures. video, and/or
audio is taken of me to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social networking sites, and other print or digital communications without payment or any other consideration. This authorization extends to all languages, media, formats, and markets now known or later discovered. I waive the right to inspect or approve the finished product wherein my likeness appears, including a written or electronic copy. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I hereby hold harmless and release Lancaster’s Luxe Lashes from all liability, petitions. and causes of action which I. my heirs. representatives. executors. or any other persons may make while acting on my behalf or on behalf of my estate.
This agreement will remain in effect for this procedure and all future follow-ups conducted by the technician. I understand that this consent agreement is legal and binding. I have read and fully understand all information in this agreement. I am over 18 years of age consent to the agreement and to brow lamination procedure.

By signing below I knowingly and willingly consent to release any and all liability for the unintent ional exposure or harm due to COVID- I9.

By signing below, I agree to the following:
I have completed t his form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any cond ition(s) that would make the requested treatment unsuitable. I will inform the technician of any d iscomfort I may experience at any time during my treatment to allow them to adjust
accordingly. I agree to waive all liability toward my technician and the salon for any injury or damages incurred due to any misrepresentation of my health.

I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. I agree I will assume the risk and full responsibility for any and all injuries. losses, side effects, or damages which might occur to me while I am undergoing this procedure. 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.
Take Photo*
Name Printed*
Signature*

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Date

MonthDayYear
Date
Geolocation*
Should be Empty:

	Check	Yes	No
Have you used any AHA products in the last 72 hours?
Are you using Retin-A, Renova, or Accutane?
Are you using any other skin thinning products and/or drugs?
Are you exposed to the sun on a daily basis?
Do you currently have a sunburn?
Do you plan on spending more time in the sun soon?
Have you recently used a tanning bed?
Have you recently had a chemical or glycolic peel?
Have you waxed before?

Brow Wax & Tint Intake Form

Brow Tint & waxing History

Medical History

Skin Care History

Consents