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Lash And Brow Tint -Form Fill

Section One
Q1

Address

Street Address
Q2

Address

Street Address Line 2
Q3

Address

City
Q4

Address

State / Province
Q5

Address

Postal / Zip Code
Q6

Do you wear contacts?
Q7

Please list any medications, over the counter or prescription you are currently using
Q8

Please list any illnesses or conditions you are being treated by a physician for
Q9

Please list any allergies you have
Q10

Have you ever had your lashes or brows tinted?
Q11

If you had an adverse reaction to a previous tinting, please explain
Q12

I understand that tinting lashes or brows has some inherent risk of irritation to the orbital eye including the eye itself, and could result in stinging or burning, blurry vision and potentially should the tint enter the eye.
Q13

I understand that if the tinting agent, developer, or mixture of both accidentally come into with my eye, my eye will be flushed with water and medical attention may be required.
Q14

I understand that some irritation, itching or burning may occur to the skin which comes into with the tinting agent.
Q15

I understand that there may be some residual dark staining left on the skin following the tinting of either my lashes, brows, or both. This will fade and go away within a short time.
Q16

I understand that while every attempt will be made to provide me with my chosen color, hair absorbs color differently and my final results may not be the color I initially wanted.
Q17

I understand that over the course of several weeks, the tint will gradually lighten and fade. Re will be required to keep the color fresh. Usually every 3 4 weeks.
Q18

Client Name (Signature)
Q19

Date

Date