Brow Stain Consent Form for Brows By Denise, LLC

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

In order to provide this service we kindly ask and require you to fill out the details and agree to the terms below. We look forward to seeing you!

Email *

Please provide your first and last name: *

Have you ever used hair color before? *

Yes

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

Yes

Do you wear contacts? *

Yes

What over-the-counter or prescription skin care products are you currently using?

Do you have diabetes, lupus, or any autoimmune disease? *

Yes

Please list any medications you are taking, including over-the-counter herbs, vitamins and supplements:

Please list any allergies you have:

Have you ever had your brows or lashes tinted before? *

Yes

If you had an adverse reaction to a previous brow/lash tint or hair color, please explain:

Please Read & Acknowledge Each Item Below

Although every precaution will be made to ensure your safety and well-being before, during and after tinting application, Please be aware of the possible risks below: Please Initial items 1 - 6

1) *

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 into the eye.

Required

2) *

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.

Required

3) *

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

Required

4) *

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

Required

5) *

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.

Required

6) *

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

Required

PLEASE READ AND ACKNOWLEDGE *

If I have any concerns I will address these with my skincare therapist. I give permission to my therapist to perform the tinting procedures we have discussed, and will hold him/her staff harmless from any liability that may result from the treatment. I have accurately answered the questions 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. In the event i have additional questions or concerns regarding my treatment, I will consult the esthetician immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraph and that I have had sufficient opportunity for discussions to have any questions answered. I understand the procedure and accept the risks. I do not hold the esthetician who's signature appears below or and Brows by Denise LLC responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be effected by the treatment performed today and in the future.

Required

PLEASE READ AND ACKNOWLEDGE *

I authorize Brows By Denise, LLC to perform the Brow Tint procedure.

Required

CONSENT: Client Full Name *

Date Signed: *

YYYY

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms