brows/lashes consent

1
Name
First Name
Last Name
2
Email
example@example.com
3
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Phone Number
Please enter a valid phone number.
5
Date
Date
Year
Month
Day
6
Are your brows microbladed?
YESNO
7
Have you ever had a reaction to any of the following?
Brow/lip wax
Brow tint
Brow lamination
Lash extensions
Facial
lash lift or tint
Another skincare service
8
Are you currently using any skin care or exfoliating products around the eyebrows with the following ingredients: Retina A, Glycolic Acid, Salicylic Acid, Alpha Hydroxy Products, Cortisone or Acne Products?
YESNO
9
If so, list them below.
10
Are you on Accutane (or anything similar?) *Using retinoids (accutane or similar) can cause skin to rip off during the waxing process. For your own safety, we cannot wax you until you have been off of Accutane or similar medications for over a year's time. *
YESNO
11
Are you pregnant or breastfeeding?
YESNO
12
Do you wear contacts?
YESNO
13
List all things you are sensitive or allergic to:
14
List any illness or condition you are currently being treated by a physician for:
15
Do you have any of the following conditions? List all that apply
Eczema
Psoriasis on the face or neck
Recent eye surgery
Recent eye infection
Sensitive skin
Sunburn
Epilepsy
16
List any medications you are on.
17
Are you ok with before/after pictures being taken and possibly used on social media?
YESNO
18
How did you hear about Studio 22 Aesthetics?
19
You may experience skin sensitivity/thinning which can result in skin lifting from the following: Sunburned skin, pregnancy, menstruation, retinol, antibiotics, certain medical conditions, or other medications not listed.
20
If you are on any of the following medication you cannot be waxed today.
Accutane, Renova, Tretinoin, Adapalene, Alustra, Avage, Isotretinoin, Avita, Differin, Retin-A, Tazarotene.
21
SignatureI understand that during the treatment, despite all precautionary measures, injury is possible I will not hold the technician or business performing this service on me responsible in any way for any damages or issues that may arise as a result of having the any procedures performed on me. I understand that some irritation, itching or burning may occur to the skin which comes in contact with some products. I understand that an allergic reaction is possible. I understand that it is imperative that I disclose all of the information requested on the Client Consent Form. I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications. I agree that if I experience any ill effects that I will contact the aesthetician that performed this procedure. I understand that aftercare will be explained to me but it is my responsibility to follow through and keep up with it.
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