Agenute

Henna Brow Intake Form
Personal Information
Name*
DOB*
Address*
Phone*
Occupation*
Email*
example@example.com
medical History

Skin Disease/DisorderCardiac DiseaseHepatitisHemophiliaInflammatory DiseaseEpilepsy/Seizure DisorderLiver DiseaseBotox/Filler InjectionsAllergiesLow Blood PressurePregnant/LactatingFaintingTuberculosis (TB)BlepharoplastyHormone TherapyHigh Blood PressureBleeding DisordersTrichotillomaniaAccutane UseMigraines/HeadachesSickle Cell AnemiaAsthmaFaceliftAutoimmune DisorderHerpes Simplex VirusNeurological DisorderCold Sores/Fever BlistersHIV/AIDS
Other
By signing below, I understand that topical creams, medical conditions, and certain medications can affect the results of henna. I understand that I can not receive henna if I have certain contraindications and I hereby release Lulus Beauté Studio & Esthetics 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 damages or loss to myself and/or property that may be caused by any act, or misinformation both intentional or accidentally on this form as well as failure to follow post-care instructions after my service.
Signature*

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Date*

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Type a question*

I agree that I am over the age of 18, am NOT under the influence of alcohol or drugs, am NOT pregnant or nursing and desire to receive the henna procedure. The general nature of henna has been explained to me.I have been informed of the nature, risks, and possible complications and consequences of henna.I understand the henna procedure may have known or unknown complications including but not limited to: infection, scarring, inconsistent color, and allergic reaction.I understand that allergies to the pigment may occur at any time.I request the henna procedure and accept the possible complications and consequences of said procedure and understand that results vary per client.I understand that If I have any skin treatments including but not limited to laser hair removal, plastic surgery, or other cosmetic procedures, it may result in adverse changes to my henna procedure and may not be correctable.I have received pre and post care instructions and I will strictly adhere to such instructions. I understand that my failure to properly follow pre and post care instructions may compromise my procedure.
I consent to allow Lulus Beauté Studio & Esthetics to consult with and evaluate me in order to determine if I am a good candidate for henna. I understand that photographs and measurements will be taken and kept in my file. I agree that these forms have been completed truthfully and to the best of my knowledge and abilities. I understand the contraindications and possible side effects of henna as discussed with staff members of Lulus Beauté Studio & Esthetics. Furthermore, I agree to waive all liabilities toward Lulus Beauté Studio & Esthetics for any injury or damages incurred due to my misrepresentation of my health history.
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Date*

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Henna Brow Intake Form

Personal Information