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)*

MonthDayYear
Default date is today
Services with Zuri you will be receiving today (check all that apply):*

Waxing (brow shaping)Tinting (on lash or brow)Lash LiftBrow Lamination
About You:
Name:*
Your Date of Birth (MM/DD/YYYY):*

MonthDayYear
Pronouns:
Your Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Email Address*
This email will get after care info. Your email will be added to our customer list.
For Tinting Info:

For brows and lashes
Have you ever had your lashes or brows tinted?*

YesNo
Have you ever had an allergic reaction to hair color*

YesNo
Do you wear contacts*

YesNo
List any allergies you have:
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:*

Yes, lash liftYes, brow laminationNoOther
Do you wear contacts*

YesNo
Are you pregnant?*

YesNo
List any allergies you have:
Do you have or are you being treated for an eye injury?*

YesNo
If yes, what kind of injury?
Have you ever had any of these conditions (check all that apply):*

AlopeciaGlaucomaMiliaCataractConjunctivitisTrichotilomaniaEczemaSensitive eyesRecent eye infectionNoneOther
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?*

YesNo
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?*

YesNo
Do you have any communicable diseases right now such as cold sores or the flu?*

YesNo
Have you experienced Botox, Restylane or Collagen injections?*

YesNo
If yes, when?
Are you taking any medications (particularly hormones, acne medication such as Accutane, antibiotics, Differin, Retinols or blood thinners (such as aspirin or Coumadin)?*

Yes, please list below.No
Do you have any other skin or health concerns or medication that you are taking, that you want to be sure we know about:
About Today:
Do you prefer a silent appointment (minimal talking/conversations with Zuri during the treatment)?

Yes please, silent appointment is preferred.No thanks, chatting is great!Other- let Zuri know.
Do you consent to photography and video of you?

Yes
Do you have any questions or concerns regarding your treatment today?
Do you have any accessibility or general needs we should be aware of to make your treatment more comfortable?
Extra Info:
Are you?

New to us at Tattoo 34 (WELCOME!)Been here, back for more!
How did you hear about us?
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.
Client's Signature*

Clear
Should be Empty:

About You:

For Tinting Info:

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:

For Lash Lift or Brow Lamination Info :

For Waxing Info:

About Today:

Extra Info:

Waiver Release and Consent