Lash and Brow Tint Consent Form

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Service being provided today

Have you used any Retinol, Vitamin A, or had your skin waxed in the past 2 weeks?

Please list any illnesses or conditions you are being treated by a physician for

Please list any skin allergies you have

Have you ever had this service done before?

YesNo

If you had an adverse reaction to a previous tinting, please explain

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:

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

I understand that if the tinting agent, developer, or mixture of both accidentally come into 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 into with the tinting agent.

I understand that there may be some residual dark staining left on the skin following the tinting 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, 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. Retint will be required to keep the color fresh. Usually every 4-6 weeks.

I have read the above information. If I have concerns, I will address them with my service provider, Allyssa Aponte. I give permission to Allyssa to perform the procedure we have discussed, and will hold her 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 that 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 my service provider, Allyssa, responsible for any of my conditions that were present, but not disclosed at the time of the skin care procedure, which may be affected by the treatment performed today.

Client Name (Signature)

Date

Service Provider: Allyssa Aponte- PMU Crew

PMU Crew Esthetics Consent Form