Brow Lamination Consent and History

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Brow Lamination Consent and History

Name *

Phone *

Email *

Today's Date *

Have you had eyebrow lamination in the past? *

Yes
No

If yes, when?

Have you had any reactions to eyebrow lamination products in the past? *

Yes
No

If yes, when?

Have you ever used hair color/eyelash tint? *

Yes
No

Have you ever had an allergic reaction to hair color/eyelash tint? *

Yes
No

Do you wear contact lenses? *

Yes
No

Are you currently using eyebrow enhancement serums of any kind? *

Yes
No

Do you have a history of recurrent eye or tear duct infections? *

Yes
No

Do you have a history of dry eyes or Sjorgen’s Syndrome? *

Yes
No

List any allergies, illnesses, medical conditions, or medical treatments you have recently used that could interfere with this brow lamination procedure.

Although every precaution will be taken to ensure my safety before, during, and after this brow lamination procedure, I understand that there are risks associated with having brow lamination. *

Please write your initials above to consent.

I understand that brow lamination is a combination of a perming and conditioning procedure. As with any perming solution, there is a possibility of skin irritation, and I will alert my technician if I should feel any discomfort during the procedure. *

Please write your initials above to consent.

I understand that, though rare, there is a possibility of irritation, infection, and eye injury if product gets in or near the eyes. Therefore, I agree to keep my eyes closed during the procedure. *

Please write your initials above to consent.

I agree that if I experience any adverse reaction, that I will contact my technician. *

Please write your initials above to consent.

I understand that the products used for this procedure may, under rare circumstances, cause irritation that require a physician’s follow-up care, even though my technician utilized correct techniques and followed proper safety protocols; if I choose to consult a physician, it will be at my own expense. *

Please write your initials above to consent.

I understand that the finished shape of my natural brows is unpredictable and will require shaping by my technician to look their best. *

Please write your initials above to consent.

I understand that the longevity of my results can be affected by both environmental and biological factors, and cannot be guaranteed. *

Please write your initials above to consent.

I understand that certain activities such as swimming, excessive physical exertion where moisture or sweating is involved may affect the longevity of my results. *

Please write your initials above to consent.

I understand and agree to follow the pre and post-care instructions provided by my technician for the best results and longevity of my procedure. I accept the consequences resulting from failure to follow these instructions. *

Please write your initials above to consent.

Please indicate if the following apply to you currently or in the past:

Pregnant/breast feeding
Skin disease, irritation, or Trauma in brow area
Eye infection
Hypersensitive skin/eyes
Psoriasis/Eczema
Sunburn
Alopecia
Ultra-sensitive skin/eyes
Blood thinners
Recent permanent makeup
Herpes Simplex
Scar tissue in the treatment area
Pink eye
Facial peel or dermabrasion (in last 2 weeks)
Exfoliation (in the last week)
Recent eye surgery
Tanning products
Brow growth serums
Taking or recently taken accutane
Recent wax in brow area
Reaction to hair dye/perm/lash lift products
Skin disease, irritation, or trauma in brow area not addressed above

If you checked accutane, when did you last take it?

If you checked waxing in the brow area, please provide date.

I have read and understood the above information. If I have any concerns, I will address these with my esthetician. 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. This agreement will remain in effect for this procedure and all future brow lamination procedures conducted by my technician. 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 associated 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 procedure that may be affected by the treatment performed today. By signing below, I certify that I have read and understand the above statements and agree to them. I also certify that all of the above is true to my recollection and that I have disclosed my medical history as it pertains to this form and the brow lamination procedure. I have been given a patch test for this product or have waived this option prior to the start of this procedure. I understand that if a patch test is offered to me and I decline, I cannot hold this technician, establishment, or product distributor/manufacturer responsible for any adverse reaction to this product or procedure under normal or intended application.

Please print your name above to sign the waiver.

Today's Date *

I give permission for my photos to be used as examples for clients and for marketing and promotional purposes.

Yes
No
Yes, but procedure area only, not full face.

Aftercare:

To maintain the longevity of your brow lamination treatment, use RevitaLash brow serum and follow alternative aftercare instructions given.
Avoid getting brows wet, saunas or hot bath for the next 24-48 hours.
Do not apply makeup to the brows for 24 hours post-treatment.
Do not apply Retin-A, AHA, BHA, or exfoliate the brow area for 72 hours before or after the treatment.
No self-tanner products should be used on the face for at least 48 hours post-treatment.
Do not use harsh cleansers and oily products in the treatment area.

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