Parent/Guardian Consent Form
Includes minor's medical history, appointment preferences, and parent's 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.
Parent's Personal Information
Parent's Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Minor/Child's Personal Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
example@example.com
Phone Number
*
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 your child is suitable and able to undergo the procedure and to rule out any contraindications
Does your child have any allergies? If yes, please explain.
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Is your child on any medications? If yes, please explain.
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Does your child have any medical condition(s) that may need accommodations during their appointment? If so, please explain what and how I may be able to accommodate them and provide a relaxing appointment.
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Does your child have, or are currently being treated for an eye infection or eye injury? How about 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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Has your child had any reactions to lash or brow products, lash glue, lash lift solutions, brow lamination solutions, hard wax, hair dye or lash/brow tint before? If yes, please explain.
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BROW LAMINATION AND/OR FACIAL TREATMENT CLIENTS ONLY: Does your child use any acne medication (topical or oral) and/or skincare with active ingredients such as, AHA/BHAs, exfoliants, retinols? How often? (They 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 their service.)
Does your child wear contact lenses? (If yes and they are coming in for any lash and/or facial services, please get them to come in to their appointment WITHOUT contact lenses as they might provide discomfort or cause an infection/reaction).
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Yes and they will come into the appointment without their contact lenses
No, they don't wear contact lenses
Would you like your child to do a patch test for lash and/or brow services prior to their appointment? This tests for any allergic reactions to any products used and is typically scheduled 3 days prior to the appointment.
*
Yes
No
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Parent Consent & Liability
This consent form is given to parents of clients under 18 years old receiving any beauty services provided by The Beauty Jem. This is to ensure both the parent and client are aware of the services they are agreeing to undergo as well as any risks associated to it.
I, the undersigned parent/legal guardian, hereby understand and give consent for my child (named above) to receive one or more of the following beauty services:
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Eyelash Extensions - synthetic eyelashes to be glued to their own natural eyelashes
Lash Lift and/or Tint - lash lift and/or tint solutions will be applied to their natural eyelashes.
Brow Lamination and/or Groom and/or Tint - brow lamination and/or tint solutions will be applied to their natural eyebrows and surrounding area.
Facial Treatment - non-invasive skin resurfacing treatment that combines cleansing, exfoliation, extraction, hydration, and skin barrier protection
I understand that it is my child’s responsibility to keep their eyes closed (for eyelash services) and be still during the entire procedure, until their technician addresses them to open their eyes and that if my child wears contacts, they must remove them. Any medical conditions that might be aggravated by lying still in a horizontal position for a prolonged time may mean they will not be able to have the procedure performed. I understand failure to keep their eyes fully shut throughout the whole procedure can lead to the risks listed below.
*
Yes
No
BROW LAMINATION AND/OR FACIAL CLIENTS ONLY: I understand that my child is 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 their brow lamination appointment. Failure to follow this can lead to the risks listed below.
Yes
No
I am fully aware of the nature, risks, and potential side effects of the selected procedure(s), which include but are not limited to: chemical burns, discomfort, eye redness, itching, pain, infection and irritation. I understand that even though my child’s technician will perform the service with precision and care, the adverse reactions may still occur and that results can vary by individual. Some clients may have an allergic reaction and require the eyelashes extensions to be removed or discontinue undergoing the chosen service. I voluntarily assume all such risks and release my child’s technician of all liability associated with receiving eyelash extensions, lash lift, facial, and/or brow lamination services.
*
Yes
No
I confirm and agree to disclose all of my child’s known allergies, eye conditions, medications, or medical issues that may affect the outcome or safety of this procedure. I disclosed all sensitivities they have to surgical tapes, cyanoacrylate, vaseline, latex, facial products/ingredients, lash lift or brow lamination solutions, lash or brow tint/dye, etc. and after the technician’s precautions I have still allowed her to proceed with application. I understand and agree that my child's technician will not be held responsible if my child experiences any issues with their eyes, eyebrows, skin, or lashes.
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Yes
No
I hereby grant to “THE BEAUTY JEM” the full right to take, publish and reproduce photographs of my child, their face, their eyes, eyebrows, and/or eyelashes, 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 understand that my child must agree to follow the care and maintenance instructions provided by the technician and that if any follow up care is required or failure to follow these instructions, this will be at their own expense and risk. I accept all consequences on behalf of my child if the aftercare instructions are not followed correctly.
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Yes
No
I acknowledge that “THE BEAUTY JEM” does not accept refund requests. I understand that I or my child must 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.
*
Yes
No
Parent/Guardian Signature – By signing below, I confirm I have read and understood the above information, had the opportunity to ask questions, and agree for my child to receive the selected beauty services.
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Submit
Submit
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