Consent for Henna Procedure:
I have agreed to allow Lash Reveal to perform the Henna tint service. Before my technician can perform this procedure, I understand I must complete this agreement and provide my informed consent by signing and dating where indicated.
Henna is a natural dye created from the Lawsonia inermis plant. It stains the skin up to 7-14 days and can last up to 4 weeks on the brow hair. It lasts particularly well on lighter hair or grey hairs. The darker you choose to go, the longer the henna stain will last on both the skin and hair. We carefully create a custom mix designed to suit your skin tone and color preferences. The henna takes around 20-30 minutes to process. Before the henna is applied, your eyebrows may be artistically mapped and pre-drawn.
1. Waiver of Liability: I understand there are risks associated with having this procedure, and that not withstanding the utmost of care in the application of these products, there still exist risks associated with the procedure and product itself, which include without limitation, skin irritation, discomfort, redness; and in rare cases, itchiness, or allergic reaction.
I have been fully informed in the methods and procedures concerning the Henna procedure. As well as the risks associated with the cosmetic procedure. I understand there is more than one technique and brands of solutions and I will not attribute any liability to Lash Reveal as a result of this procedure. I also agree to indemnify and hold harmless Lash Reveal from any and all claims, actions, expenses, damages, and liabilities that may be asserted as a result of having this procedure done or the purchase of the service.
It has been represented to me that no guarantees, warranties, promises, commitments or other statements as to the results of this treatment have been made acknowledge that I have no particular representation or guarantees and I am consenting to this procedure at my own risk. All conditions must be revealed or disclosed to my technician regarding my health history, medications that have been or are being taken and any past reactions to products or medications taken.
2. Permission to Use Pictures: I hereby grant Lash Reveal the full rights to take, publish and reproduce photographs of my eyes and or eyelashes, before, during and after this procedure, for advertising, education, or other purposes. I further assign any copyright in these photos to Lash Reveal. I also grant consent to use my image and likeness as contained in these photos for any advertising or other purposes.
3. Care and Maintenance: I agree to follow the care and maintenance instructions provided by Lash Reveal for the use and care of my brows, and if any follow up care is required due to my own mistake or negligence, or failure to follow these instructions, this will be at my own expense and risk.
Keep brows dry for at least 24 hours, This includes shower stream, washing your face, and sweating from working out. Exfoliating your face will cause the henna stain to fade quicker. To maintain the stain, avoid exfoliating the brow area. Avoid using makeup on your brows when they have been freshly done. Using a clear brow gel is fine, however, filling them in with a product in the first 48 hours of having them done can cause the henna to fade quicker.
I acknowledge that I have completely read through Lash Reveals FAQ and Aftercare pages and can reference back to them at anytime to view these before or after service.
4. No Known Medical Conditions / Informed Consent: I have read and completed the Client Intake Form in its entirety and in truth. I acknowledge that I have been advised of the potential harmful or negative side effects that the procedure may cause to those who have specific medical or skin conditions. I understand that the products or tools used could in rare cases cause allergic reactions or irritation. I understand that the procedure requires that I lay still for the services entirety with my eyes shut. I further state that I have no known medical condition that might aggravated by the procedure or any medical condition that would prevent me from complying with or heeding to the professionals instructions or these warnings.
This agreement will remain in effect for this procedure, and all future Henna Tint procedures conducted by Lash Reveal.
I am not to my knowledge allergic to any of these above listed ingredients.
I understand and acknowledge that I should avoid Henna if I have G6PD deficiency, been advised to avoid Fava beans, Quinine, are extremely anemic, have serious citrus allergies or essential oil allergies.
I realize that my Henna Brow procedure is temporary and will potentially be staining my skin for 7-14 days and will start to fade as soon as 24 hours after procedure is complete.
I realize that my Henna Brow procedure will be tinting my eyebrow hair up to 4-6 weeks.
I understand that results vary with everyone. Overall skin conditions and aftercare will ultimately affect the retention of the Brow Henna results.
Client can request that a patch test is performed ascertain potential allergic reaction to the henna products. Pigments being used have a low probability of allergic reaction but cannot absolutely rule out the possibility of allergic reaction.
The patch test has been discussed with the client. By signing the client DOES NOT request a patch test.
** If a patch test is requested it will be completed on a seperate form **
Client holds Lash Reveal harmless and absolves all liability resulting from allergic reactions to henna products.
Lash Reveal utilizes sterilized and/ or disposable equipment to minimize the risk of infection or contamination.
While the risk of infection from our procedures is extremely small, the possibility of such an occurrence cannot be totally precluded. Accordingly, client understands and accepts this risk and releases Lash Reveal from any and all liability related to the subject procedure, expecting instances involving gross negligence.
I understand there will be absolutely no refunds.
I agree to inform Lash Reveal, of any medical changes or procedures done that may interfere with future services.
I acknowledge that I have read these statements in their entirety and fully understand the waiver, I certify that I am of sound mind & understand their may be other unknown risks not reasonable foreseeable at this time.
I agree that this agreement is binding upon me, and my heirs, I represent that I am over 18 years of age and that I have the right to enter this agreement, or if I am under 18 years of age, I have had my parent or legal guardian consent to this agreement, and his or hers relationship is as follows: