Brow Lamination + Tint Consent Form
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
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Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
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Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
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Kansas
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Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Montana
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New Hampshire
New Jersey
New Mexico
New York
North Carolina
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
Format: (000) 000-0000.
Email
*
Emergency Contact
*
List full name and number of emergency contact.
What brow service are you having?
*
Brow Tint
Brow Lamination
Signature Brow Design
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Are you experiencing any of the following health conditions currently?
*
None
Epilepsy/Seizures
Skin Lesions
MRSA
Ocular Herpes
Contagious Skin Disease(s)
Cancer/Tumors
Eye Infection/Conjunctivitis
Keloids/Hypertrophic Scars
Eczema/Psoriasis/Dermatitis
Open Cuts/Wounds
Scar Tissue
Fainting/Dizziness
Alopecia
Trichotillomania
Facial Swelling
Sunburn
Claustrophobia
Are you pregnant or breastfeeding?
*
No
Yes
Have you had any recent surgeries around your eyes, head or face?
*
No
Yes
Have you received chemotherapy or radiation in the past 12 months?
*
No
Yes
Are you currently using anticoagulants (such as Warfarin, Xarelto, Plavix, Eliquis, etc.) or other medications, like aspirin, that thin the blood and/or interfere with blood clotting?
*
No
Yes
Any known allergies, anaphylactic reactions or sensitives to:
*
None
Latex
Relaxers
Pigment or Dye
Perms
Phenylenediamine (PPD)
Hair Dye
Ammonia
Makeup
Peroxide
Adhesives
Provide additional information for any known skin or eye irritant or allergy not listed above.
*
Type N/A if NONE was checked.
Have you had a chemical peel in the last 30 days?
*
No
Yes
Have you taken Accutane or any other oral acne medication within the last 12 months?
*
No
Yes
Have you used any products that contained Retinol/Retin-A, AHAs (Glycolic, Lactic, Azelaic, Mandelic), BHAs (Salicylic), PHAs (Gluconolactone, Galactose, Lactobionic) in the last 2 weeks?
*
No
Yes
Have you recently had permanent makeup (PMU) applied to your brow area?
*
No
Yes
Have you experienced an adverse reaction to this or a similar service before?
*
No
Yes
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I consent to Miona Naturals: Esthetics + Spa to take photos and/or videos of me immediately prior to, during and/or after my procedure. I authorize Miona Naturals: Esthetics + Spa to copyright, edit, use and publish these photos and/or videos. I consent to Miona Naturals: Esthetics + Spa using such photos and/or videos for the purpose of documentation, education, social media, advertising and web content. I may indicate if I prefer not to have my full face shown. I understand that I will not receive any monetary compensation for usage of my photos and/or videos.
*
Yes
I have voluntarily elected to undergo this treatment and understand the nature and purpose of this treatment, and are aware of possible benefits, risks, and complications. I recognize there are no guaranteed results and that independent results are not only dependent upon age, skin condition and lifestyle but also commitment to the treatment plan and home care recommendations from the esthetician. I understand that the aftercare instructions for this treatment will be delivered to me via email post-treatment. I understand how important it is to follow all after care instructions. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will contact the esthetician immediately. I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies. I understand that all of my health information will remain confidential. I agree to keep the esthetician updated as to any changes in my medical history and understand that there shall be no liability on the esthetician's part should I forget to do so. By signing below, I consent to and authorize Miona Naturals: Esthetics + Spa and the esthetician, Brittany Miona Ward, to perform my service. I acknowledge that I have read and fully understand all information detailed above. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I hold the esthetician, Brittany Miona Ward, and the institution, Miona Naturals LLC, harmless from any liability that may result from this treatment. I understand rude or offensive behavior and language is NOT tolerated at any time and that the esthetician, Brittany Miona Ward, and the institution, Miona Naturals LLC, reserves the right to refuse service at any time.
*
Yes
Client/Parent Signature
*
Esthetician Name:
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