Client Consent Form
Consent form for lash and brow tinting. Please complete the form using the wording from the provided PDF and keep fields optional unless the PDF clearly requires them.
Client Information
Name
First Name
Middle Name
Last Name
Address
City
State
Zip
Home/Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Client History and Screening
Have you ever used hair color before?
Yes
No
Have you ever had an allergic reaction to hair color?
Yes
No
Do you wear contacts?
Yes
No
What over-the-counter or prescription skin care products are you currently using?
Do you have diabetes, lupus, or any auto-immune disease?
Yes
No
If yes, describe (auto-immune disease)
Illnesses or conditions you are being treated by a physician for
Medications you are taking, including over-the-counter herbs, vitamins and supplements
Allergies
Have you ever had your brows or lashes tinted?
Yes
No
If you had an adverse reaction to a previous tinting, please explain
Consent and Risk Acknowledgments
I acknowledge that I have read and understood the information provided to me.
*
I understand that the services may involve certain risks and potential side effects.
*
I have had the opportunity to ask questions and have received satisfactory answers.
*
I understand that participation is voluntary and I may stop at any time.
*
I acknowledge that no guarantees or promises have been made regarding outcomes.
*
I consent to proceed with the services described above.
*
Signature and Authorization
Client Name (Printed)
*
Client Signature
*
Client Signature Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Esthetician Name
*
Esthetician Signature Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: