Lash & Brow Service Consent Form

First Name

Last Name

Phone Number

Address

How did you hear about us?

Have you ever used hair dye before?

Have you ever had an allergic reaction to hair dye?

Do you wear contact lenses? if yes, did you bring your solution and case with you today?

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

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

Do you have any skin conditions?

Do you have any allergies or sensitivities?

Have you previously had your eyebrows or eyelashes dyed or permed or laminated (lamination is for brows only) If yes, when?)

Did you experience any adverse reactions?

Are you pregnant or breastfeeding?

I understand that I must notify my technician immediately if I notice any sensation in the area of the service.

I understand that if I am pregnant, I should not have any chemical service for the duration of my pregnancy; however, it is my choice to do so.

I understand that tinting lashes / brows offers a risk of irritation to the eye and orbital area that could result in stinging or burning, blurry vision and potentially blindness should the dye enter into the eye.

I understand that if the hair dye, developer, perm solutions or mixture accidentally comes into contact with my eye, my eye will be flushed with water and that I may need to seek medical attention at my cost.

I understand that some irritation, itching or burning may occur to the skin whic`h comes into contact with the products used for these services.

I understand that there may be some residual dark staining left on the skin following the tinting process and that this will fade and disappear within a short time.

I understand that, while every attempt will be made to provide me with my chosen result that hair can absorb dye differently and my final result may not be the color I initially requested.

I understand that over the course of several weeks the tint will gradually lighten and fade and that if I use exfoliating and other skincare ingredients on these areas or if I swim in chlorinated water the results of the service will fade faster.

Touch-ups will be required to keep the tint color looking fresh (3-4 weeks)

I understand the procedure and accept the risks and agree to keep my eyes closed at all times unless otherwise instructed to do so.

I have accurately answered all the questions including listing all known allergies, prescription drugs or products I am currently ingesting or using topically.

I have had sufficient opportunities for discussion to have any questions answered.

I will not hold my technician responsible for any of my conditions that were present but not disclosed at the time of this procedure.

I give permission to the technician to perform the service(s)

Please choose one of the following

I consent to a 24 -hour patch test

I refuse to a 24 -hour patch test and accept the risks involved that have been explained to me.

Your Signature

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Date