Waxing/Tinting Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age?
Have you used any Alpha Hydroxy Acids (AHA) or glycolic products in the past 48-72 hours?
*
Yes
No
Have you used Retin-A, Renova, or Accutane within the past year?
*
Yes
No
When?
-
Month
-
Day
Year
Date
Are you diabetic?
*
Yes
No
Are you using any other skin thinning products and/or drugs that thin the blood?
*
Yes
No
Do you use tanning beds and/or are exposed to the sun on a regular basis?
*
Yes
No
Are you currently taking any medications that I need to know about? If so, please list.
Do you have any allergies?
*
Yes
No
Please list your allergies
Have you ever used hair tint before?
*
Yes
No
Have you ever had an allergic reaction to hair tint?
*
Yes
No
Yes, and I give permission to try again.
Have you had an allergic reaction to wax?
*
Yes
No
Although every precaution will be made to ensure your safety and well-being before, during and after your tinting application, please be aware of the possible risks below. Please initial:
I understand that tinting lashes or brows has some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging or burning, blurry vision and potentially blindness should the tint enter into the eye
I understand that if the tinting agent, developer, or mixture of both accidentally comes into contact with my eye, my eye will be flushed with water and medical attention may be required.
I understand that some irritation, itching or 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, brows or both. This 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 fade. Re-tinting will be required to keep the new color fresh. Most clients need to re-tint every 3-4 weeks.
Please note that waxing/tinting can have certain side effects such as skin removal, redness, swelling, tenderness, etc.
*
I have read the above information. If I have any concerns, I will address these with my skin care therapist. I give permission to my therapist to perform the tinting procedure we have discussed, and will hold him/her and his/her staff harmless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, or products I am currently ingesting or using topically. I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the esthetician immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. 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. 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
Date
*
-
Month
-
Day
Year
Date
Signature
*
Submit
Submit
Should be Empty: