Clone of Brow Lamination Consent Form

1
Full Name* This field is required.
First Name
Last Name
2
Your Suburb and Post Code* This field is required.
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
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.
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
9
Precautions and Considerations* This field is required.Brow lamination is known as brow perming or brow lift. It involves straightening the brow hairs using a chemical solution. Right after appointment, the brows will look very sleek and have a wet look about them, similar to freshly microbladed brows. Please read carefully some precautions and considerations before proceeding with the service: 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 lamination service today
YESNO
10
Is this the first time you have had brow lamination?* This field is required.
YESNO
11
If this is not your first time getting brow lamination, where and when have you had them applied?
Please type salon name and your last appointment date with them
12
Would you like to have brow dye applied today?* This field is required.
YESNO
13
Which dye colors do you prefer?* This field is required.
Black
Graphite
Blue Black
Chestnut
Light Brown
Classical Brown
Dark Brown
14
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
15
Waiver of liability* This field is required.I agree to having my eyebrows laminated today. I understand that there are rare risks associated with the procedure such as skin irritation, allergic reaction, dehydration of hair, and discomfort could occur. I agree that if I experience any of these conditions with my lashes and 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, materials, tapes, cleansers, wax, tint, 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
16
Care and maintenance* This field is required.WITHIN 48 HOURS Keep your brows dry and avoid contact with water or steam or any moist environment that may cause your brows to become damp and wet. After 48 hours, you may swim, shower, and exercise as per normal GENERAL CARE 1. Use castor oil / brow gel / brow soap to help the laminated brow hairs to stay in place. You can do this in the morning along with your make up routine 2. Avoid putting make up over the brow area 2. When cleansing face thereafter, wipe around the brow area, avoid excessive cleansing or exfoliating the brow 3. When swimming apply oil or barrier cream to prevent premature lightening 4. Avoid applying resurfacing serums 5. Please note during the first 24 hours the brow 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 brow dye is temporary and potentially staining my skin for up to 2 weeks, and will gradually fade as soon as 24 hours after the procedure is complete. I understand the result varies for everyone and overall skin and brows conditions and after care will ultimately affect the retention of brow lamination result. 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
17
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 lamination 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
18
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
19
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
20
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
21
You have to agree to our terms and conditions before services can be provided to you
Should be Empty: