Brow Henna Consent / Liability Waiver

1. Today's Date *
2. Please tell us about yourself! *
3. What is your birth date? *
4. Referred By: *
5. If you were referred by someone you know, please tell us who! We like to give referral bonuses to our clients who refer us! If you were referred by an event, please tell us which one!
6. Is this your first brow henna? *
7. If you've had henna or brow tint before, did you experience any adverse reaction to either service?
8. If yes, please describe the reaction.
9. Did you seek medical advise from a doctor or specialist as a result of this reaction?
10. If yes, what was the advice of your doctor/treatment given?
11. CURRENT CONDITIONS, PREVIOUS DISCOMFORT, STINGING OR ADVERSE REACTIONS: Please tick any that apply: *
12. List any medications you're on:
After Care
Avoid access hot water and steam on the brows for the first 24 hours. 

Avoid shampoos & conditioners, makeup & makeup removers, creams, and serums on the brow area for the first 24 hours. 

When cleansing the face and brow area after the first 24 hours, cool water will help the henna to last longer than using warm/hot water. 
Agreement
I understand that there are risks associated with the Brow Henna procedure, as with any beauty treatment.

I understand that the brows and skin will be stained with henna.  

I also understand that I will need to be lying in a reclined position for 30-60 minutes.

This agreement will remain in effect for this brow henna procedure and future brow henna procedures conducted by my technician or any other technician conducting business at Butterfly Kiss Lash Studio. 

I understand that this agreement is binding and that I have read and fully understand all information above. I represent that I am over the age of 18 years. If below 18 years of age a parent or guardian must also sign this form.

I release my technician or salon/spa Butterfly Kiss Lash Studio from all liability associated with this procedure.

I understand that I have been advised to follow the aftercare protocol from my technician so as to avoid any discomfort or adverse side effects after the procedure has been completed.

RESULTS MAY VARY. Our eyebrows are each unique and require slightly different processing times based on our skin's oiliness or dryness. If desired results are not achieved, processing times will be adjusted for future henna applications. There are no guarantees for how long the brow henna will last, on average it lasts on the skin between 7-14 days and on the hair 6-8 weeks. Our company or salon is not responsible for any technician errors. 

I request and consent to these procedures being carried out today without undergoing a sensitivity patch test. The sensitivity test, which if conducted, may indicate my sensitivity / allergy to the products. I understand the contents of this form and take full responsibility for my actions, thus absolving all other parties of their responsibilities, if any, associated with the supply of the products and services(s).
Authorization For Use or Disclosure of Client Photographic and/or Video Images
AUTHORIZATION: I authorize the use and disclosure of my name, photographic/video images, and/or testimonial for marketing purposes by the practice/salon listed below. I understand that information disclosed pursuant to this authorization may be subject to redisclosure and may no longer be protected by HIPAA privacy regulations.
PURPOSE: The photographic/video images, and/or testimonial will be used for: Social Media and/or Advertising
REVOCABILITY: I understand that I may revoke this authorization at any time, but such revocation must be in writing and received by the practice/salon via registered mail. Revocation a?ects disclosure moving forward and is not retroactive. This authorization expires 99 years from date signed.
NO TREATMENT CONDITIONS: I understand that the practice/salon cannot condition treatment on whether or not I sign this authorization. 
Please ask your lash artist for a copy of this if you desire one. 
13. May we use your photos/videos per the above paragraph? *
Please sign here *