Henna Brow Consent Form

Patient's Name

First NameLast Name

Date of Birth

Date

Date of Appointment

Date

Gender

MaleFemale

Phone Number

Please enter a valid phone number.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Skin Type

SensitiveOilyDryNormal

How did you hear about us?

Is this your first time having a brow henna procedure?

YesNo

If not, please tell us more about your previous experience in brow henna?

Do you have any allergies like skin allergy or skin asthma?

YesNo

If yes, please tell us more about the allergies that you have

I understand that Henna is temporary; not permanent, and it might take less than a month to fade. I understand that on rare occasions allergic reactions may still occur after providing all my known allergens upfront. I understand that the brow henna Brows By Q contains, Sodium Percarbonate, Cellulose Gum, Henna (Lawsonia Inermis) Leaf Powder, Rose Petals (Rosa Damascene) Powder, Citric Acid, Magnesium Sulphate, Silica, HC Yellow No 4., m-aminophenol sulfate, p-aminophenol sulfate, sodium silicate, sodium sulfate, xanthan gum, p-Phenylenediamine Sodium Lauryl Sulphate, Para Aminophenol, 4-chloro Resorcinol, 4-Amino-2-Hydroxytoluene, Aloe Vera (Aloe Barbadensis) Leaf Powder, Saffron (Crocus Sativus) Oil, Jojoba (Simmondsia Chinensis) Oil, Dodecylbenzene sulfuric acid, cetearyl alcohol, disodium EDTA, cetrimonium chloride, parfum, squalene, pullulan glycerin, polysorbate 20, alcohol, sodium PCA, Benzil Alocohol arginine, ethylparaben, dehydroacetic acid, methylparaben, achroyrocline satureioides flower extract, propylparaben, butylparaben, isobuyparaben, verbascum thapsos extract, fabiana imbricata leaf/stem extract, achilles millefolium extract, phenoxyethnaol ethylhexylglycerin and benzyl salicylate. a I confirm that I am not allergic to any of these ingredietns. I confirm that there are no guarantees, warranties, or promises regarding the result of the procedure. I understand that I need to follow the instructions provided to me by the professional before, during, and after the procedure. I understand that a photo needs to be taken for the before and after documentation. I understand that there will be no refund to be issued to me if the procedure requires after-care expenses, in the event of any unsatisfactory result and misconception on my part. I read and reviewed this form thoroughly before submission to the best of my knowledge and ability. I confirm that all information in this document is accurate and true I understand that If I am 17 years old below I am required to get my Parent or Guardian signature.

Patient Signature

Date Signed

Date

If minor, please provide the additional information:

Parent/Guardian Name

First NameLast Name

Parent/Guardian Phone Number

Please enter a valid phone number.

Relationship (Father, Mother, etc.)

Parent/Guardian Signature

Date Signed

Date

Henna Brow Consent Form

Consent Agreement