Brow Lamination and/or Brow Tinting Intake
Brow Lamination is a "perm" applied to brow hairs to relax and comb into desired shape.
Brow Tint is a tint applied to brow hair.
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Email *
Name *
Email *
Address, City, State, Zip *
Phone number *
Emergency Contact Name *
Emergency Contact Phone Number *
How Did You Hear about MT Brow Bar? *
Required
Who referred you? (MT Brow Bar offers a Referral Program)
I am over the age of 18 and not under the influence of any drugs or alcohol.  *
Are you pregnant or nursing? *
Desired treatment *
Required
ANY previous Permanent Makeup, Lash Lift, Last Tint, Brow Lamination, Brow Tint or Henna services?  If so which service and when? *
Were there any complications/reactions/sensitivities or generalized complaints from ANY of the above mentioned services? If yes, please describe
Do you have any exciting events coming up? Wedding, honeymoon, vacation, etc? Please explain and include date
Allergies *
Have you ever had a reaction to a black tattoo *
Please list ANY medications/supplements (especially fish oil, krill oil, turmeric, etc) you are taking. If none please state "none" *
General Medical. Select any that apply *
Required
Other medical history not mentioned in previous section
Please check any of the following that may apply to you: *
Required
Skin *
Required
Tanning Bed Use *
Do you spray tan *
Last spray tan
Are you a fitness model/body builder?
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History of COVID? Date of last COVID illness? *
Need a “Quiet Appointment”?  (Artist will be as quiet as possible during service to allow for the most relaxing experience possible)
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Recent facial surgeries? List below, including date/year
Any recent Botox, PDO Threads, Surgeries, Microdermabrasion (or any other esthetician services) or Dermal Fillers in BROW region? If yes please explain below. 
We recommend to reschedule after: Botox 2 weeks, Dermal Fillers 2 weeks, PDO Threads 8 weeks, Microdermabrasion minimum 4 weeks and surgeries in brow region 12 weeks *
We also recommend to reschedule if you have any active acne, lesions, rash or any skin irritations (even sunburn) in the brow region until any of the above issues are under control or have subsided
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I understand I must stop use of Retinol, Retinol-A, AHA, BHA, Glycolic Acids and anything considered to be an exfoliant at least 7 days prior to my procedure.I further understand that if I do not follow these directions, my skin may be red, irritated and/or sensitive after my procedure. *
All waxing services must take place no less than 72 prior to your lamination/tint service. I also understand MT Brow Bar does not offer waxing as a part of my service *
I understand that my Brow Lamination procedure will be perming/straightening my brow hair for up to 6 weeks and Brow Tinting will be tinting my brow hair for up to 6 weeks
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I UNDERSTAND THAT MY BROW LAMINATION/BROW TINTING PROCEDURE IS TEMPORARY
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I UNDERSTAND THAT RESULTS MAY VARY WITH EVERYONE. OVERALL SKIN CONDITIONS AND AFTERCARE WILL ULTIMATELY AFFECT THE RETENTION OF THE BROW LAMINATION/BROW TINTING RESULTS   
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I have read and answered all questions truthfully to my knowledge and understand that results of treatments like Brow Laminations and Brow Tinting can vary from client to client due to skin and lifestyle.
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I will follow all aftercare protocols to the best of my ability
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I hereby authorize MT Brow Bar to perform a Brow Lamination and/or Brow Tinting treatment.
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I will not hold MTBB or their facility liable for any complications that can occur post treatment. Ex: rash, hair loss or skin irritations
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I understand that I am required to submit a minimum of 3 photos of my brows or lashes (procedure area) without makeup to MTBB within 48 hours of booking my appointment OR 72 hours prior to my appointment(whichever is soonest).  Please initial below.Photos can be sent to 936-870-7021 or mtbrowbar@gmail.com *
I understand that this client questionnaire is required to be completed a minimum of 72 hours prior to my appointment(if possible).  Please initial below *
I consent to the procedure of a brow lamination and/or brow tint *
I understand there are risks associated with having a brow lamination and/or brow tint *
I understand that as part of the procedure, skin irritation or discomfort could occur.  I agree that if I experience any of these medical conditions I will contact MT Brow Bar and consult a physician's follow-up care. *
  I understand that even though my technician laminates and/or tints the brow hairs using the proper technique, the instruments, tapes, cleaners, eye gel pads, adhesives, tint products, lamination products and removers used may irritate my eyes/brow area/skin or require a physician’s follow-up care.  
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I understand the following aftercare:
Brow Lamination:
You should also avoid wetting, touching, or messing with your brows for at least 24 hours after the treatment. This will give them time to settle into their new shape. This includes avoiding exercise or anything that will cause you to sweat excessively, sauna or hot tub use.

Brow Tinting:
Avoid wetting, touching or messing with brows for at least 24 hours. This includes sweating excessively or sauna/hot tub use *
I understand the following (Brow Lamination):
It's possible that you may lose some brow hairs after the treatment. This is usually just temporary and your brows will grow back within a few weeks.
If you do experience hair loss, it's important to not pick at the area. This can cause scarring and make it more difficult for your brows to grow back *
  I realize and accept the consequences of failure to adhere to the aftercare instructions as it may negatively affect the brow lamination/tint.  
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I understand and consent to having my eyes closed for the duration of the 60-90 minute procedure *
  I release my technician from all liability associated with this procedure, which is performed with the utmost attention to safety and proper application using tools and products that the technician has been professionally trained to use  
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  I understand there are no guarantees for length of time the brow hairs will stay permed/laminated or tinted  
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  BROW LAMINATION/TINTING CONSENT, RELEASE AND WAIVER OF LIABILITY AGREEMENT

 I, the undersigned (“Customer”), consent to have a brow lamination applied to my eyebrows (the “Service”) by and his/her/its staff assistants, contractors and employees (collectively herein, the “MT Brow Bar”). The Service and its associated risks have been explained to me by Mt Brow Bar in terms that I understand. The explanation included:
 • The benefits of the Service;
 • The nature of the Service and how the Service will be performed;
• The types of materials and adhesives used during the Service;
 • The most frequently occurring risks of the Service, and those risks which are unlikely to occur but which may involve serious consequences, including but not limited to the risk of experiencing: (a) an allergic reactions to the material used to perm the eyebrows, (c) redness and/or skin irritation (d) an eye injury due to material falling on or into the eye; and (e) an eye or other injury occurring during the performance of the Service;
• How to properly care for the brow lamination applied during the Service; and
• How often I should expect to need to repeat the Service and the best methods for caring for the brow lamination after the Service is performed; and
• Factors that affect retention of the brow lamination.
I was given the opportunity to ask MT Brow Bar any questions I have regarding the Service and I have had those questions answered to my satisfaction. Based on the foregoing, I hereby assume all of the risks associated with the Service, whether known or unknown, including, but not limited to, the risk of personal injury or property damage. As consideration for MT Brow Bar performing the Service, I forever release MT Brow Bar and his/her/its respective directors, officers, members, managers, employees, agents, contractors, attorneys, representatives, successors and assigns from any and all actions, claims, or demands that I, my assignees, heirs, next of kin, spouse, personal representatives and legal representatives now have, or may have in the future, for injury, death, or property damage, in any way related to the Service.

By signing at the end of this paragraph, I grant MT Brow Bar permission to reproduce, publish, distribute or otherwise use in any reasonable manner my name, photograph, likeness and statements, including, but not limited to, before and after pictures of my eyes and eyelashes in connection with the promotion of the Service or the products used in the Service (or other similar services and products) in all media, including without limitation, the internet, news articles, advertisements, or other electronic or printed materials. If my signature is not present at the end of this paragraph, then the above-described permission has not been granted.  (Please sign below)
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ACKNOWLEDGMENT (please read entire section below)
-I’m over the age of 18 and not under the influence of ANY illegal drugs or alcohol. (or I am under the age of 18 and will have my parent complete a Parent Consent Form provided by MT Brow Bar)

-  I’m not pregnant or nursing, and it has been at least 6 months since I've last nursed.

- If any unforeseen condition arises in the course of the procedure to be performed, I authorize my technician to use his or her professional judgment to decide what he/she feels is necessary under the given circumstances.

- All known allergies to pigments, adhesives and dyes have been disclosed to MT BROW BAR.

- I accept and am knowingly and voluntarily consenting to the permanence of the procedure as well as the possible known and unknown complications and consequences of said procedure(s).

 -I have been informed that the highest standards of hygiene are met for each individual client, procedure and visit.
 
- I understand that I may have to return for a repeated procedure.
 
- The result of the procedure can be affected by the following: medication, skin characteristics (dry- oily- sun-damaged thick or thin skin type)- personal pH balance of your skin, alcohol intake, smoking, and post procedure aftercare.

- To my knowledge, I do not have any physical, mental or medical impairment or disability that might affect my well-being as a direct or indirect result of my decision to have the procedure done at this time.

- I have fully and truthfully advised MT BROW BAR of any and all medication for depression or any other mood altering prescription(s)

 - I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the technician. Failure to do so may jeopardize my chances for a successful procedure.

- I have been informed of the nature, risks, and possible complications and consequences of Brow Lamination/Brow Tint

- I understand that if I have any skin treatments, injectables, laser hair removal, plastic surgery or other skin altering procedure, it may result in adverse changes to my procedure.

- I understand that the taking before and after photographs of the said procedure(s) are a condition of such procedure(s).

I have read and understand the risks listed ABOVE and they have been explained to me. I certify that the information in the above questionnaire is accurate and that it has been explained to me in detail and my questions have been answered. I accept full responsibility for any complications that may arise or result during or following the cosmetic procedure(s) to be performed at my request (Sign name below)

  To my knowledge, I do not have any mental or medical impairment or disability which might affect my well-being as a direct or indirect result of my decision to have a Brow Lamination/Brow Tint procedure done at this time. I assume full responsibility for my decision to have this procedure(s) and release ASHLEY SYKORA/MT BROW BAR from any and all liability both now and in the future.

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If I insist on driving, I waive all responsibility to my practitioner and I assume full responsibility that I can see to drive, perfectly.
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I agree to pay for any and all damages and injuries to any persons and property belonging to ASHLEY SYKORA/MT BROW BAR to who they may become liable contractually or by operation of law, caused by or resulting from my decision to have a Brow Lamination/Brow Tint procedure at this time.
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I fully understand the procedure and give permission to ASHLEY SYKORA/MT BROW BAR to perform the service of Brow Lamination and/or Brow Tint and all procedure(s) and steps involved.
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 I CERTIFY THIS FORM HAS BEEN FULLY EXPLAINED TO ME AND THAT I HAVE READ IT OR IT HAS BEEN READ TO ME. I UNDERSTAND ITS CONTENTS AND I WILL NOT BE DISBURSED A REFUND DUE TO POOR LAMINATION AND/OR TINTING RETENTION.   
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I am voluntarily receiving this procedure. I understand that there are risks associated with this procedure.  Injuries or outcomes may arise from my own or other’s actions.  I am assuming all risks of the procedure(s), whether known or unknown to me. I accept full and complete responsibility.

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  I understand that all negatives, together with prints or video shall become and remain the property of ASHLEY SYKORA/MT BROW BAR solely and completely. I agree to allow MTBB to utilize any/all photos taken pre/post procedure for use of social media, education and record keeping. (Full photo release). *


I hereby grant irrevocable consent to and authorize the use of any reproduction by ASHLEY SYKORA/MT BROW BAR, any and all photographs which are taken this day of me, negative or positive proof which will be hereby attached for any purposes whatsoever, without further compensation to me. *
I release from liability and waive my right, and the right of my heirs, assigns, and legal representatives to bring a claim against ASHLEY SYKORA/MT BROW BAR, its representatives, agents, or employees and its subsidiaries (“collectively “MT BROW BAR”) for any and all claims, including claims of ASHLEY SYKORA/MT BROW BAR alleged negligence, resulting in any physical injury, illness (including death) or economic loss I may suffer or which may result from my participation in the procedure(s).  
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I have read this document, and I am signing it freely. I understand the legal consequences of signing this document, including (a) releasing ASHLEY SYKORA/MT BROW BAR from all liability, (b) waiving my right and the right of my heirs, assigns, and legal representatives to sue ASHLEY SYKORA/MT BROW BAR, (c) and assuming all risks of participating in the procedure(s).

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