Clone of Brow Waxing Consent Form

1
Full Name* This field is required.
First Name
Last Name
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Your Suburb and Post Code* This field is required.
Street Address
Street Address Line 2
City
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3
Phone Number* This field is required.
4
E-mail* This field is required.
example@example.com
5
Date of birth* This field is required.
DD/MM/YYYY
6
How did you hear about us?* This field is required.
Google
Social media
Word of mouth
Passing by
Others (Please specify...)
7
How did you hear about us? Others (Please specify...)
8
Please tick any of the following that applies to you:
Laser skin resurfacing
Taking antibiotics
Face Sunburnt
Diabetes
Face tan
Use of retinoid for skin treatment
Chemical Peel /Microdermabrasion
Hormonal imbalance
Alopecia
Pregnancy
Allergies to tint / henna / dye
Sensitive / dehydrated skin
Other
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Precautions and Considerations* This field is required.1. You must wait a minimum of seven (7) days before waxing after a light chemical peel or microdermabrasion 2. The potential for skin reactions and/or lifting is likely when the skin is manually exfoliated 7 days prior to waxing, such as home microdermabrasion scrubs 3. Waxing shouldn't be performed if you have had laser skin resurfacing within the past year 4. Waxing shouldn't be performed if you have had a physician administered peel within the past year 5. Women may experience sensitivity to waxing up to a week prior and during their period 6. Sunburnt, extremely tanned or irritated areas cannot be waxed 7. Thin, fragile, dehydrated or sensitive skin may burn, tear or bruise from waxing procedures 8. Diabetics have a hard time healing, when a wound or lesion occurs to the skin, there may be complications 9. Allergies to any of the ingredients in the wax and/or pre and post wax products may cause severe allergic reaction. This may include inflammation, redness, itchiness, and potentially skin lifting 10. Pregnancy may cause discolouration to the hair once tinted due to hormonal changes I confirm that I have read the precautions and considerations mentioned above and would like to proceed with brow styling service today
YESNO
10
Is this the first time you have had brow waxing?* This field is required.
YESNO
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If this is not your first time getting brow waxing, where and when have you had them applied?
Please type salon name and your last appointment date with them
12
Permission to use pictures* This field is required.I hereby grant my service provider the full right to take, publish and reproduce photographs of me, my face, my eyes and/or brows, both before and after the procedure, for any advertising, education, or other purposes whatsoever.
YESNO
13
Waiver of liability* This field is required.I agree to having my eyebrows waxed. I understand that there are rare risks associated with the procedure such as skin irritation, allergic reaction, and discomfort could occur. I agree that if I experience any of these conditions with my brows that I will contact professional technician and my GP to seek for immediate medical attention. Whilst proper techniques and procedure will be performed by the brow artist, the instruments, tapes, cleansers, wax, henna, and other product use may irritate my skin/brows. I further agree that I will not hold Mollylash or any of its employees responsible should there be any unfavourable result. I acknowledge and consent to the use of CCTV cameras with microphones in the reception area for the purposes of quality assurance and training. I understand that these recordings are used to enhance service quality and for staff training purposes. Please note that no refund will be given under any circumstances.
YESNO
14
Care and maintenance* This field is required.WITHIN 48 HOURS Keep your brows dry and avoid contact with water. Avoid sweating excessively or use oil based make up remover on your brows. After 48 hours, you may swim, shower, and exercise as per normal WITHIN THE FIRST WEEK Avoid steam rooms, saunas, and steam facials GENERAL CARE 1. When cleansing face thereafter, wipe around the brow area, avoid excessive cleansing or exfoliating the brow 2. When swimming apply oil or barrier cream to prevent premature lightening 3. Avoid applying resurfacing serums 4. Please note during the first 24 hours the henna or dye stain will develop into a darker colours as it reacts with the keratin of the skin. It will lighten gradually day by day CONFIRMATION I understand that minor discomfort and redness may occur due to the waxing I understand the result varies for everyone and overall skin and brows conditions I agree to follow the maintenance instruction provided to me by my technician, and that if any follow up care is required due to my own mistake or negligence, or failure to follow these instructions, this will be at my own expense and risk.
YESNO
15
No Known Medical Conditions / Informed Consent* This field is required.I have read and completed the Client Consent Form in its entirety and in truth. I understand that I need to disclose any allergies that I may have to materials or equipment used in brow waxing service. I further state that I have no known medical condition that might be aggravated by the procedure or any medical condition that would prevent me from complying with or heeding to instructions or these warnings. This Agreement will remain in effect for this procedure, and all future procedures.
YESNO
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Signature* This field is required.I agree that this Agreement is binding upon me, and my heirs, legal representatives and assigns. I represent that I am at least 18 years of age and that I have the right to enter this agreement.
I am over 18 years old
I am under 18 years old
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Signature of legal guardian* This field is required.I agree that this Agreement is binding upon me, and my heirs, legal representatives and assigns. I am under 18 years of age and I have my parent or legal guardians consent to this agreement.
Clear
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Signature* This field is required.I agree that this Agreement is binding upon me, and my heirs, legal representatives and assigns. I represent that I am at least 18 years of age and that I have the right to enter this agreement
Clear
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You have to agree to our terms and conditions before services can be provided to you
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