Brow Lamination (and Tint/Groom) Form
Includes medical history, appointment preferences, and consent & liability. Please fill it out truthfully and to the best of your ability, it should only take around 5-10 minutes. Should you have any questions or concerns, feel free to contact me at beautybyjemdj@gmail.com or Instagram @thebeautyjem.
Personal Information
Name
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First Name
Last Name
Date of Birth
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-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Instagram username – this is my preferred form of contact (If you don't have one, I will be contacting you through text).
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Medical History
Please answer carefully and truthfully for your aesthetician to determine whether you are suitable and able to undergo the procedure and to rule out any contraindications.
Do you have any allergies? If yes, please explain.
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Are you on any medications? If yes, please explain.
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Do you use any acne medication (topical or oral) and/or skincare with active ingredients such as, AHA/BHAs, exfoliants, retinols? How often? (You will need to avoid using these for at least TWO weeks before your appointment as it can cause a reaction with the products used during your service.)
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Do you have any medical condition(s) that may need accommodations during your appointment? If so, please explain what and how I may be able to accommodate you and provide a relaxing appointment.
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Do you have, or are currently being treated for an infection, injury, active acne breakouts, sunburn, tear, cut, or any skin condition around your eyebrow area? If yes, please explain.
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Have you had any reactions to brow products, hair dye, brow tint, hard wax or brow lamination products before? If yes, please explain.
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Are you pregnant or breastfeeding? This service is not recommended during first trimester or breastfeeding.
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Yes, I'm in the first trimester
Yes, I'm in the second trimester
Yes, I'm in the third trimester
Yes, I'm breastfeeding
No
Would you like to do a patch test prior to your appointment? This tests for any allergic reactions to any products used and is typically scheduled 3 days prior to the appointment.
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Yes
No
What do you prefer during your appointment? (By the way, you can always ask for a silent appointment, just write it in your appointment notes when you book or let me know in person!)
Music and talk
Podcast and listen
Own headphones/sound
Silent appointment (minimal talking & music/podcast)
Other (please let me know at your appointment!)
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Consent & Liability
I confirm I am over the age of 18 or have obtained parental/guardian consent.
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Yes
No, I will get my parent/guardian to sign the Parent Consent form
I understand I am receiving a brow lamination treatment and/or tint and/or groom from "THE BEAUTY JEM/JEMIMA DE JESUS". I understand there are risks associated with having this service done on my natural eyebrows.
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Yes
No
I understand that it is my responsibility to be still during the entire procedure and any medical conditions that might be aggravated by lying still in a horizontal position for a prolonged time may mean I will not be able to have the procedure performed on my eyebrows.
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Yes
No
I understand I am not allowed to use acne medication (topical or oral) and/or any skincare that includes active ingredients such as, AHA/BHAs, exfoliants, and retinols for at least two weeks prior to my brow lamination appointment. Failure to follow this can lead to the risks listed below.
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Yes
No
I understand that some risks of this procedure may be, but not limited to, itching, discomfort, redness, irritation, and infection of the brow and/or face area. I understand that even though my technician will perform the service with precision and care, the products used during this procedure may cause these issues. Some clients may have an allergic reaction and may have to discontinue undergoing this service. I voluntarily assume all such risks and release my technician of all liability associated with receiving a brow lamination and/or tint and/or groom.
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Yes
No
I confirm and agree to disclose all known skin conditions, allergies, medications, or medical issues that may affect the outcome or safety of this procedure. I disclosed all sensitivities I have to brow lamination solutions, brow tint/dye, latex, etc. and after my technician's precautions I have still decided to proceed with application. I understand and agree that my technician will not be held responsible if I experience any issues with my eyebrows or skin.
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Yes
No
I hereby grant to “THE BEAUTY JEM” the full right to take, publish and reproduce photographs of me, my face, my eyes and/or eyebrows, both before and after this procedure, solely for marketing purposes on a website or social media without any monetary compensation and/or discount vouchers.
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Yes
No
I agree to follow the care and maintenance instructions provided by the artist and that if any follow up care is required or failure to follow these instructions, I acknowledge this will be at my own expense and risk.
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Yes
No
I acknowledge that “THE BEAUTY JEM” does not accept refund requests. I agree to communicate any fallout or dissatisfaction within 72 hours of the appointment to guarantee a same week touch-up appointment or removal.
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Yes
No
I have read and understood the policies of “THE BEAUTY JEM” (found on her website or Instagram @thebeautyjem story highlights with the name “policy”). I understand that those policies and this consent and liability form will be in effect from now and all future appointments and will be applied if necessary and as “THE BEAUTY JEM” sees fit.
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Yes
No
I understand this agreement shall be governed by the laws of British Columbia. This agreement will remain in effect for this procedure, and all future procedures conducted by “THE BEAUTY JEM”. I release my aesthetician of “THE BEAUTY JEM/JEMIMA DE JESUS”, and the property owners of all liability and claims associated with this procedure.
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Yes
No
Signature – By signing below, I confirm I have read and understood the above information, had the opportunity to ask questions, and agree to receive the brow lamination and/or groom and/or tint service.
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Submit
Submit
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