Lash/Brow Tint Medical History & Consent/Liability Form

MEDICAL HISTORY & CONSENT/LIABILITY FORM

The 425 Waxing Studio
Client Name

First NameLast Name
Date of birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Please take a moment to answer the following questions
Are you currently taking any medications?
Please list
Do you wear contacts?
Do you have any allergies to cosmetics, food, or drug?
Have you been to the doctor in the last week?
Have you received botox or filler within the last two days?
Have you ever had your brows or lashes tinted?
Have you ever had an adverse reaction to a product, treatment, or previous tinting around your eyes and brows? If yes, please explain:
Do you prefer a silent appointment?
Are you okay with photos/videos being posted of your service?
How did you hear about The 425 Waxing Studio?
I understand that tinting lashes or brows has some inherent risk of irritation to the orbital eye including the eye itself, and could result in stinging or burning, blurry vision and potentially should the tint enter the eye.?
I understand that if the tinting agent, developer, or mixture of both accidentally come into with my eye, my eye will be flushed with water and medical attention may be required.
I understand that there may be some residual dark staining left on the skin following the tinting of either my lashes, brows, or both. This will fade and go away within a short time.
Terms & Conditions

I have read the above information, and if I have any concerns, I will address these with my esthetician. I permit my therapist to perform the tinting procedure we have discussed and will hold her harmless from any liability that may result from this treatment. I have given an accurate account of the questions asked above, including all known allergies, prescription drugs, or products I am currently ingesting or using topically. I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. I am willing to follow recommendations made by my esthetician for a home care regimen that can minimize or eliminate possible negative reactions. In the event that I may have additional questions or concerns regarding my treatment or suggested home product / post-treatment care, I will consult the esthetician immediately. I agree that this constitutes full disclosure and supersedes any prior verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the esthetician responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.
Policies (PLEASE READ)

By agreeing to our policies, you understand that this appointment at The 425 Waxing Studio is reserved exclusively for you and requires 24-hour notice for cancellation or rescheduling. Canceled appointments within 24 hours will incur a 25% cancellation fee, and No-shows will be charged 30% of the service price unless spoken to in advance to arrange. No Children under 12 in the studio unless arrangements have been made with Waxer, 620-418-2802.
By submitting this form, you acknowledge and agree that this document serves as proof of your consent and participation. Any attempt to dispute the transaction will be met with this evidence, confirming that you have willingly filled out and agreed to the terms stated.
Client Signature
Date

MonthDayYear
Date
Should be Empty: