AGELESS PERFECTION SKIN CARE STUDIO
Lash and Brow Tinting Client Intake & Consent
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Email *
Name (First & Last) *
Street Address-City-State-Zip *
Contact Information (Email Address) *
Contact Information (Mobile Phone Number) *
Emergency Contact (Name & Mobile Number) *
Birthday *
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Is it okay to add you to our email list? *
May we take before and after pictures for evaluation and marketing? *
Which tint service are you requesting? *
What tint color are you requesting? *
Have you ever used hair color before? *
Have you ever had your lashes or brows professionally tinted/dyed before? *
Have you ever had an allergic reaction to hair color? *
Do you wear contact lens? *
What over the counter, professional or prescription skin care products are you currently using? *
Do you have diabetes, lupus or any auto-immune disease? *
Please list ALL illnesses or health conditions you are being treated by a physician for. *
Please list ALL medications (prescription and over-the-counter) you are currently taking. *
Please list ALL allergic reactions you have experienced. *
Every precaution will be made/taken to ensure your safety and well-being before, during and after your tint application.  Please be aware of the following possible risks. *
1) I understand that tinting brows or lashes 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. *
 2) I understand that if the tint product (developer or mixture) accidentally comes into contact with my eye, my eye will be flushed with cool water and medical attention may be required. *
 3) I understand that some irritation, itching or burning may occur to the skin which comes in contact with the tint product. *
 4) 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 away within a short time. *
5) I understand that while every attempt will be made to provide the chosen color, everyone's hair absorbs color differently and the final results may not be the color initially desired. *
6) I understand that over the course of 4-6 weeks, the tint will gradually lighten and fade. Schedule your next appointment for re-tinting to keep the color fresh. *
7) I understand and will follow the post care instructions provided to me to allow for the full benefit of my tinting service. *
PLEASE NOTE - READ CAREFULLY! No Show/Late Cancellation Police:  A NO SHOW by you for a scheduled appointment will result in a $100 NO SHOW FEE due upon receipt of invoice sent to your email address(es) on file. Any cancellation made in less than 24-hour of your appointment will result in a $75 LATE CANCELLATION FEE due upon receipt of invoice sent to your email address(es) on file.  If you are more than 15 minutes late, your appointment will have to be rescheduled in order for me to provide you and the person scheduled after you the best possible service. *
I have read and completed this intake questionnaire truthfully. I understand that withholding information or providing false information may result in contraindications and/or irritation to the skin from the treatment(s) received. The treatment(s) I receive are voluntary and I release Ageless Perfection Skin Care Studio and/or the Licensed Esthetician from liability. *
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