A Spa to Remember Eye Lash and Brow Tinting Consent Form

Address*

Would you like to receive weekly text messages of our specials?*
YesNo

Have you ever used hair color before?*
YesNo

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

Do you wear contact lenses?*
YesNo

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

Do you have diabetes, lupus, or any auto-immune disease?*
YesNo

If yes, please describe

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

List any allergies you have*

Have you ever had your eyelashes / eyebrows tinted?*
YesNo

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

Name on Card*

Card Number*

I understand that tinting lashes and 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 the both accidentally come 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 in 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. Retinting will be required to keep the new color fresh. Most clients need to re-tint every 3-4 weeks.

By entering your name, date and signature below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge.

I have read the above information. If I have any concerns, I will address them with my esthetician. I give permission to my esthetician to perform the tinting procedure we have discussed. I have accurately answered the questions above, including all known allergies, prescription drugs, or products I am currently ingesting or using epically. 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, ad that it supersedes any previous verbal or written disclosures. I certify that I have read, an 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 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.