Tinting Form

Name

First NameLast Name

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Date

I understand that tinting lashes or brows has some inherent risk of irritation to the orbital eye area, including the eye itselfand could result in stinging or burning, blurry vision and potentially blindness should the tint enter the eye.

I understand that if the tinting agent, developer, or mixture of both accidentally comes in contact with my eye, my eye will be flushed with water and medical attention may be required understand that some irritation, itchingor burning may occur to the skin which comes in contact with the tinting agent.
I understand that there may be some residual dark staining left on the skin following the tinting process of either my lashes, browsor bothThis will fade and go away within a short time. I understand that, while every attempt will be made to provide me with my chosen color, everyone's hair absorbs color differently and my final results may not be the color I initially wanted.

I understand that over the course of several weeks, the tint will gradually lighten and fadeRe-tinting will be required to keep the new color fresh. Most clients need to re-tint every 3-4 weeks.
I have read the above information. If have any concerns, I will address these with my skin care therapistI give permission to my therapist to perform the tinting procedure we have discussed, and will hold them and their staff harmless from any liability that may result from this treatment, have accurately answered the questions above, including all known allergies, prescription drugsor products am currently ingesting or using topicallyI understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possibleIn the event I may have additional questions or concerns regarding my treatmentI will consult the esthetician immediatelyagree that this constitutes full disclosure, and that it supersedes and previous verbal or written disclosures. I certify that have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. understand the procedure and accept the risks. I do not hold the esthetician, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.

Signature