Eye brow Lamination Consent

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Must be filled out prior to appointment .

All Information will be Confidential .

Full name *

Phone number *

Email *

Birthdate *

YYYY

Are you 18 years or older ? *

If you are younger than 18 years old , please have a parent or guardian sign their name below AND accompany you to your appointments.

Do you have any allergies ?

If no N/A

Have you ever received a brow lamination in the past ? *

Yes

Required

If yes, in the past have you ever had any type of reaction during or after an eye brow lamination ?

Yes

If you've ever had a reaction to an eye brow lamination, please explain below.

Please describe what kind of eye brow look you’re wanting to achieve *

How did you hear about me ? *

Have you used any acid based products

(for example: lactic acid, salicylic acid, or glycolic acid)

Any harsh exfoliants, skin thinning products/drugs or topical medication (for example: Retin-A or any other Vitamin A products)

in the last 2 weeks ?

Yes

Have you used Isotretinoin / Accutane in the last year ?
*

Yes

CONTRAINDICATIONS FOR EYE BROW LAMINATIONS.

Please be honest with your esthetician and check any boxes that may apply to you .

Currently using any acid based products Example: glycolic , salicylic, lactic, retinoids, etc. in the last two weeks

Recent injectables

Recent eye procedures

Sensitive skin

Pregnant or Breastfeeding

Eczema / Psoriasis / Rosacea

Sun burnt skin

Any medical conditions or taking any medications that may affect the treatment such as diabetes, heart conditions, or blood thinners

Other:

Required

I understand that the eyebrow lamination, or the eyebrow lamination + tint treatment is a cosmetic procedure that involves the application of chemicals to my eyebrows.

I understand that the above information is important for my safety and the success of the treatment. I declare that the information given above is accurate and completed to the best of my knowledge.

I acknowledge that I have provided accurate and complete information about my medical history and any conditions or allergies that may affect the treatment.

I understand that it is my responsibility to inform the technician of any changes to my medical status before each treatment.

I understand that the technician will provide me with post-treatment instructions, and i agree to follow these instructions to the best of my ability.

I acknowledge that I am fully responsible for the care of my eyebrows after the treatment, and I agree to follow the aftercare instructions provided to me.

I understand that I may be liable for any expenses or damages incurred as a result of my failure to follow post-treatment instructions or my neglect of my eyebrows after the treatment.

By signing my name below, I confirm that I have read, understood, and agreed to the terms of this consent and liability agreement.

I Authorize Briana Campos, Licensed Esthetician to Take, Edit, and Post photos of me during our appointment and use them as Advertisement / Content .

If YES sign your name below .

If NO sign N/A

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