Henna Consent Form Name * First Name Last Name Guardian's Name : (in case when the client is a minor) First Name Last Name I hereby, agree to have Henna applied on my skin. By signing this agreement, I consent to the application of henna on my skin by a Brows on Fleek technician. I understand that on rare occasions there are risks associated with application of henna on the skin such as redness, itching, burning, swelling, blisters, and/or scarring of the skin. I agree that if I experience any of these conditions with my skin 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 have been informed that Henna is a temporary stain and will fade over time, that it is not a tattoo and is not permanent. A light to medium dark stain may be achieved after application and removal (after henna paste is kept on skin for minimum 4-6 hours) but the stain darkens overnight. I understand and agree to the after-care instructions provided by the certified technician for care of temporary henna stains. I realize and accept the consequences of failure to adhere to these instructions may decrease the time the henna stain 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. • Current use of any kind of prescription or over the counter. • Current allergies or sensitivities. • Recent history of chemotherapy. • History of G6PD deficiency. • Use of nonsteroidal anti-inflammatory drugs or Quinine. • Other medical conditions which would prohibit or compromise application of henna. • Others (please specify) : 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!
