Chemical Service Indemnity Form

Chemical Service Indemnity Form

For Brow Lamination, Lash Lift/Lamination, and Tint/Stain Services
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate*

MonthDayYear
Date
Cell Phone Number (For Text Communications)*
Please enter a valid phone number.
Email (Used only for secondary form of communication)*
example@example.com
Emergency Contact (First & Last Name, Phone #)*
Please list first and last name and phone number of Emergency Contact.
Please list all allergies or sensitivities:*
DISCLAIMER: Failure to provide full and complete information may result in adverse reactions to the treatment at no fault of the therapist.
Please list all medications and supplements currently taken, including over-the-counter and street drugs:*
DISCLAIMER: Failure to provide full and complete information may result in adverse reactions to the treatment at no fault of the therapist.
Have you ever received a brow or lash chemical treatment (lash lift, brow or lash lamination, lash extensions, tinting or staining, etc.) in the past?*

YesNo
If you answered 'Yes' to the question above, please list the service(s) you've received, and when you last received it. If you answered 'No', simply type "N/A".*
If you answered 'Yes' above, please list any adverse reactions that you had to the service(s). If you answered 'No', simply type "N/A".*
Are you currently pregnant?*

YesNo
Please check any of the following that apply to you:*

Past reaction to a product patch testPrevious reaction experienced to the same or similar service in the pastSkin condition such as: Eczema, Dermatitis, Psoriasis, Lesions or Sores, Open Wounds (please note below whether or not the area to be treated has ever been affected)Past or present contagious skin disease such as: Herpes, Chicken Pox, or ShinglesSkin trauma, cuts, abrasions, burns or swelling in the immediate area(s) to be servicedActive infections such as Impetigo or ConjunctivitisChemotherapy (please provide medical clearance from doctor)Recent operations around eyes, head, or face, or scar tissue in immediate area(s) to be servicedHypersensitive skin/eyesAlopeciaAny disease or disorder that causes shaking, twitching, or involuntary erratic movementsSteroid or cortizone creams (please provide medical clearance from doctor)Use of brow or lash growth serumsSpray tans or self-tanning lotionsVery dry skinPregnant or lactatingUse of contraceptive or Hormone Replacement Therapy (HRT)Recent microblading or tattooing service (must be fully healed; please provide date below)Botox and dermal fillers (please provide details and date below)Anti-acne medication such as Roaccuataine, doxycycline, epiduogel, etc. (please list below)Anti-aging creams such as Vitamin A, Retinols, AHAs and BHAs (please list below)Brow henna application (please provide date below)SunburnTrichotillomania (recurrent, irresistible urge to pull out one's own hair)None
If you checked any of the above, please elaborate here:*
Type "N/A" if you did not check anything above.
For your safety, please list any other relevant health or product usage information that may be necessary for determining the safety of the service:*
By checking this box, I understand that there is a 48 HOUR cancelation/appointment change policy, with a late fee of up to 100% of the originally scheduled service price. (See full Cancelation Policy on the website.)*

Yes, I understand I may have to pay 100% of the originally scheduled service price if I cancel or change my appointment with less than 48 hours notice.
By checking this box, I understand and agree that any illegal activity or requests for illegal activity will result in immediate dismissal and will be reported to the authorities.*

I understand and agree.
AGREEMENT:
With my signature below, I request and I consent to these procedures being carried out with or without undergoing a sensitivity patch test. The sensitivity test, which if conducted may indicate sensitivity/allergy to the products. However, I understand that even with no reaction to a patch test, a reaction may still occur at any time during or after the service. I fully comprehend the contents of this form and take full responsibility for my actions and choice to proceed, thus absolving all other parties of their responsibilities, if any, associated with the supply of the product(s) and service(s). I understand that results may vary, and it may take multiple treatments to determine proper timings and tint/stain formulas to achieve desired results.

By signing below, I also agree that all information provided is complete and honest. I have read and agree to all policies, disclosures and disclaimers provided via www.lotusorganicsdayspa.com.
Signature*

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Are you sure you have read and agreed to all separate policies and disclaimers published on the website?*

No, I have not read them, but I am checking this box to acknowledge that I accept full personal responsibility for any and all outcomes resulting from future issues that may arise. I will not hold Lotus Organics Day Spa & Wellness or Lisa Parnell responsible for any adverse reactions or termination of services resulting from not adhering to the written policies.Yes, I have read and agree to all policies and disclaimers published on the website.
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