Lash Lift & Eyebrow Lamination/Tint Consent Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Which service will you be receiving?
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Brow Lamination
Brow Lamination and Tint
Lash Lift
I have NOT had an of the following services done in the last 7 days
Microneedling
Dermaplanning
Chemical Peel, Microdermabrasion
Brow wax, Tweezing, Shaving Brows
Had Brow Lamination in the LAST 6 weeks
If none of the above, type initial below
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Are you currently using RETIN-A or ACUTANE? (Must stop Retin-a at least 3 days prior to appointment and 6 months if using ACUTANE)
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Yes
No
Have you ever used hair dye before?
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Yes
No
Have you ever had an allergic reaction to hair dye?
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Yes
No
Do you have any skin conditions?
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Yes
No
If yes, please describe
Are you currently being treated by a physician for any illness, virus, infection, or condition? (If yes, describe)
Have you previously had your eyebrows dyed or permed?
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Yes
No
Are you pregnant?
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Yes
No
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 (initial)
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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). (initial)
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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 2-3 weeks (initial)
*
YOUR SKIN MAY BE SENSITIVE IF YOU ARE:
- Pregnant, Diabetic, Taking antibiotics, or are on your menstrual cycle.
PLEASE BE AWARE THAT BROW LAMINATION MAY CAUSE:
- Redness and Swelling around the eyebrow area - Some irritation, Itching, Burning Sensation or can cause an Allergic Reaction.
AGREEMENT
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. 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, from any liability that may result from this service(s) I will not hold the technician, whose signature appears below, 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.
AGREEMENT
I REQUEST AND CONSENT TO THIS SERVICE BEING CARRIED OUT TODAY WITHOUT UNDERGOING A SENSITIVITY PATCH TEST. I UNDERSTAND THE CONSENTS OF THIS FORM AND TAKE FULL RESPONSIBILITY FOR MY ACTIONS, FOLLOWING ALL BEFORE AND AFTER CARE BEING PROVIDED, THUS ABSOLVING THE KIANA TRAN OF THEIR RESPONSIBILITIES, IF ANY ASSOCIATED WITH THE SUPPLY OF THE PRODUCT AND SERVICE(S).
BROW LAMINATION/ LASH LIFT WILL LAST APPROXIMATELY 4-6 WEEKS DEPENDING ON SKIN TYPE/ AFTERCARE**
PLEASE WAIT 6 WEEKS PRIOR TO SCHEDULING ANOTHER BROW LAMINATION/ LASH LIFT **
Date
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Month
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Day
Year
Date
Signature
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