Lash + Brow Consent Form

Lash + Brow Consent Form
Name*

First Name Last Name
Date of Birth*

MonthDay Year
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Are you currently being treated by a physician for any illness, virus, infection or condition?*

YesNo
If yes, please describe.*
Have you ever used hair dye before?*

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

YesNo
If yes, please describe.*
Have you ever previously had your eyebrows or eyelashes dyed or permed (only relevant for lash and brow services)?*

YesNo
Did you experience any adverse reactions?*

YesNo
If yes, please describe.*
Do you have any allergies or sensitivities?*

YesNo
If yes, please describe.*
Are you pregnant?*

YesNo
Although every precaution will be taken to ensure your safety and well-being before, during and after your service it is important that you are aware of the possible risks listed below:

I understand that I must tell my technician immediately if I notice any sensation (good or bad) in the area of the service.I understand that if I am pregnant I should not have any chemical service for the duration of my pregnancy; however it is my choice to do so. I consent to a 24 hour patch test.I understand that tinting eyelashes or eyebrows offers a risk of irritation to the eye and orbital eye area that could result in stinging or burning, blurry vision and potentially blindness should the dye enter into the eye.I understand that if the hair dye, developer, perm solutions or mixture thereof accidentally comes into contact with my eye, my eye will be flushed with water and that I may need to seek medical attention at my cost.I understand that some irritation, itching or burning may occur to the skin which comes into contact with the products used for these service(s).I understand that there may be some residual dark staining left on the skin following the tinting process; this will fade and disappear within a short time.I understand that, while every attempt will be made to provide me with my chosen result that hair can absorb dye differently and my final result may not be the color I initially requested.I understand that over the course of several weeks the tint will gradually lighten and fade and that if I use exfoliating and other skincare ingredients on these areas or if I swim in chlorinated water the results of the service(s) will fade faster. Touch-ups will be required to keep the tint color looking fresh (3-4 weeks).
I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks and agree to keep my eyes closed at all times unless otherwise instructed to do so. I have accurately answered the questions above, including listing all known maladies, allergies, prescription drugs or products I am currently ingesting or using topically. I understand that my technician will take every precaution to minimize or eliminate negative reactions as much as possible. In the event that I may have additional questions or concerns regarding my treatment, I will consult the technician immediately. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures.

I give permission to the technician to perform the service(s) we have discussed and I will hold them, the salon and its staff harmless from any liability that may result from this service(s). I will not hold the technician or Rawe Beauti Skin + Body Bar responsible for any of my conditions that were present but not disclosed at the time of this procedure, which may be affected by the treatment performed today.
Today's Date*

MonthDay Year
Date
Signature*

Clear
Patch Test*

I confirm that a dye patch test was carried out and that I have been informed that I will need to check the area for 24 to 48 hours to ensure that no redness, itching, swelling or blistering has occurred. If any of these reactions do occur I will gently but thoroughly wash the test area with soap and warm water, rinse the area with cool water and then pat the area dry. I will then inform the technician as soon as possible and relay any and all information regarding the reaction(s) that occurred.
Patch Test Results*

I REACTED – DO NOT PROCEED WITH SERVICE(S)I DID NOT react – I consent to proceed with the following service(s) and I accept full responsibility for any reaction which may occur.
Check service(s) requested:*

Lash TintingLash LiftLash Lift DeluxeBrow TintingBrow LaminationBrow Lamination Deluxe
PATCH TEST REFUSAL
I understand that a skin or other patch test may determine if I will have a reaction to the products tested within 24 to 48 hours, however I waive my option to a Patch Test and wish to proceed with the following services:
Check service(s) requested:*

Lash TintingLash LiftLash Lift DeluxeBrow TintingBrow LaminationBrow Lamination Deluxe
I accept full responsibility for any reaction which might occur.
Do you wear contact lenses?*

YesNo
Did you bring your solution and case with you today?*

YesNo
Today's Date*

MonthDay Year
Date
Signature*

Clear
By clicking/tapping/touching/selecting or otherwise interacting with the "Submit" button below, you are consenting to signing this Document electronically. You agree your electronic signature ("E-Signature") is the legal equivalent of your manual signature on this Document. You consent to be legally bound by this Document's agreement(s), acknowledgement(s), policy(ies), disclosure(s), consent term(s) and condition(s). You agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature. You may request a paper version of an electronic record by writing to us. We reserve the right to charge a reasonable fee for the production and mailing of a paper version of the record. Your current valid email is required for all communications.
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