Eyebrow Tinting Consent Form Name : * First Name Last Name Guardian's Name : (in case when the client is a minor): First Name Last Name Phone : * (###) ### #### Email : I hereby, agree to have an eyebrow tinting procedure performed on my eyebrows. By signing this agreement, I consent to the Eyebrow Tinting procedure by a Brows on Fleek technician. I understand that on rare occasions there are risks associated with having the eyebrow tinting dye applied to my natural eyebrows. I further understand that in rare cases as part of the procedure skin irritation and discomfort could occur as a result of the use of the instruments, tapes, cleaners, eye gel pads, adhesives and/or removers. I agree that if I experience any of these conditions with my skin and/or eyes that I will contact the certified technician that performed this procedure and that it may be beneficial to contact emergency medical services without delay, at my own expense. I understand and agree to the after-care instructions provided by the certified technician for the use and care of my eyebrows. I realize and accept the consequences of failure to adhere to these instructions may decrease the time the tinting will last. I am informing the certified technician of the following conditions by marking with a check: • Current use of anything such as oil-containing sunscreen or moisturizer around the eyes. • Current use of any kind of prescription or over the counter. • Current allergies or sensitivities. • Recent history of chemotherapy. • Other medical conditions which would prohibit or compromise application of chemical dye. • Others (please specify) I agree to the following eyebrow tinting follow-up and maintenance instructions: • No oil-based products around the brow area. • No water can come in contact within the brow area for 24 hours after the application. This agreement will remain in effect for this procedure and all future follow-ups conducted by the certified technician, and will hold the technician/s harmless from any liability that may result from this procedure. I read English and understand that this consent agreement is legal and binding. 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 agreement clauses, and that I have had sufficient opportunity for discussion to have all my questions answered. I understand the procedure and accept the risks. I do not hold the technician 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. I further agree that I will not hold Brows on Fleek or its affiliates or any of its employees responsible should there be any unfavorable outcome or result. Date : * MM DD YYYY Thank you!
