Client And Consent Form - Lash And Brow Tinting printable pdf download

Client and Consent: Lash and Brow Tinting

Name: _________________________________________________________________________________________________

Address: _______________________________________________________________________________________________

City:____________________________________________________________ State: ____________ Zip: _________________

Home/Cell Phone: ________________________________________ Work Phone:____________________________________

Email address: ___________________________________________________________________________________________

Have you ever used hair color before? Yes/No

Have you ever had an allergic reaction to hair color? Yes/No

Do you wear contacts? Yes/No

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

________________________________________________________________________________________________________

Do you have diabetes, lupus, or any auto-immune disease? Yes/No (If yes, describe) ______________________________

________________________________________________________________________________________________________

Please list any illnesses or conditions you are being treated by a physician for: ____________________________________

________________________________________________________________________________________________________

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

________________________________________________________________________________________________________

List any allergies you have: ________________________________________________________________________________

Have you ever had your brows or lashes tinted? Yes/No

If you had an adverse reaction to a previous tinting, please explain: _____________________________________________

________________________________________________________________________________________________________

Although every precaution will be made to ensure your safety and well-being before, during and after your tinting

application, please be aware of the possible risks below. Please initial:

_____ 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.

_____ 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 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.

I have read the above information. If I have any concerns, I will address these with my skin care therapist. I give permission to my

therapist to perform the tinting procedure we have discussed, and will hold him/her and his/her staff harmless from any liability

that may result from this 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 may 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 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, whose signature appears below, 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.

Client Name (Printed) _____________________________________________________________________________________

Client Name (Signature) _______________________________________________________ Date: ______________________

Esthetician __________________________________________________________________ Date: ______________________

Client And Consent Form - Lash And Brow Tinting

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