Henna Brow Consent Form

Henna Brow Consent Form
Patient's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
MaleFemale
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SensitiveOilyDryNormal
How did you hear about us?
YesNo
If not, please tell us more about your previous experience with Brow Henna
YesNoI have some allergies not related to topical products (medication, food, environmental)
If yes, please tell us more about your allergies.
Consent Agreement
I understand that Henna is temporary; not permanent, and it might take less than the max time to fade.

I understand that on rare occasions allergic reactions may still occur after providing all my known allergens upfront.

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 there will be no refunds 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 16 years old below I am required to get my Parent or Guardian signature.
Patient Signature*

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Date Signed

MonthDayYear
Date
Photography Consent
I understand that a photo needs to be taken for the before and after documentation.

I understand that there also may be video taken of my eyebrows before, during and after treatment.

I consent to the possible use of my images for advertising, marketing, and/or social media purposes.
Signature*

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If client is a minor, please provide the additional information:
Parent/Guardian Name

First NameLast Name
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship (Father, Mother, etc.)
Parent/Guardian Signature

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Date Signed

MonthDayYear
Date
Should be Empty:

Henna Brow Consent Form

Consent Agreement

Photography Consent

I understand that a photo needs to be taken for the before and after documentation.

I understand that there also may be video taken of my eyebrows before, during and after treatment.

I consent to the possible use of my images for advertising, marketing, and/or social media purposes.

If client is a minor, please provide the additional information: