Esthetic Services Waiver- Tattoo 34

  • 4035 SE Hawthorne Blvd Portland, OR 97214

  • What date is your treatment being done? (This waiver needs to be filled out the day of)*
     - -
  • Services with Zuri you will be receiving today (check all that apply):*

  • About You:

  • Your Date of Birth (MM/DD/YYYY):*
     - -
  • Format: (000) 000-0000.

  • For Tinting Info:

    For brows and lashes
  • Have you ever had your lashes or brows tinted?*
  • Have you ever had an allergic reaction to hair color*
  • Do you wear contacts*

  • Although every precaution will be made to ensure safety and well being before, during and after your tinting application, please be aware of all the possible risks below:

    I understand that tinting lashes or brows has some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging or burning, blurry vision and potentially blindness should the tint enter the eye.

    I understand that if the tinting agent, developer, or mixture of both accidentally comes into contact with my eye, my eye will be flushed with water and medical attention may be required.

    I understand that some irritation, itching or burning may occur to the skin which comes in contact with the tinting agent. 

    I understand that there may be some residual dark staining left on the skin following the tinting process of either my lashes, brows or both. This will fade and go away within a short time.

    I understand that while every attempt will be made to provide me with my chosen color, everyone's hair absorbs color differently and my final results may not be the color I initially wanted. 

    I understand that over the corse of several weeks the tint will gradually lighten and face. Re-tinting will be required to keep the color fresh. Most clients re-tint every 3-4 weeks. 

  • For Lash Lift or Brow Lamination Info :

  • Have you ever had these services before? check all that applies:*
  • Do you wear contacts*
  • Are you pregnant?*
  • Do you have or are you being treated for an eye injury?*
  • Have you ever had any of these conditions (check all that apply):*

  • For Waxing Info:

    For brow shaping
  • Have you used a scrub, glycolic, microdermabrasion, had laser hair removal, electrolysis, used a tanning bed or waxed the area of today's treatment in the last 30 days?*
  • Do you use Retin-A, Renova, had a deep chemical peel by a doctor, facial surgery or laser-resurfacing or used Accutane within the last 18 months?*
  • Do you have any communicable diseases right now such as cold sores or the flu?*
  • Have you experienced Botox, Restylane or Collagen injections?*
  • Are you taking any medications (particularly hormones, acne medication such as Accutane, antibiotics, Differin, Retinols or blood thinners (such as aspirin or Coumadin)?*

  • About Today:

  • Do you prefer a silent appointment (minimal talking/conversations with Zuri during the treatment)?

  • Extra Info:

  • Are you?

  •  Waiver Release and Consent

    I am not under the influence of any type of drugs or alcohol. 

    I understand there is the possibility of an allergic reaction or irritation (or resulting infection) to the soap, agents, developer, or other items/processes used in my treatments. 

    I understand that aftercare, lifestyle, and maintenance will effect my results. I also understand that if I have any skin treatments, laser hair removal, plastic surgery, injections, or other skin altering procedures, may result in adverse changes to my treatments. 

    I understand there are security cameras in public areas of the shop. Footage is only reviewed to address any concerns (we haven't had any).

    I agree to these statements entirely of free will and sound mind. 

  • By signing below I am agreeing to all of the above statements and that I have fully read, responded truthfully and give consent to receive services by Zuri at Tattoo 34. I understand withholding information or providing misinformation may result in contradictions and/or irritation to the skin from treatments received. The treatments I receive are voluntary and I assume any and all risks that may arise. 

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