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[Kanata] Brow lamination consent form
Brow Lamination Consent - Personal information section
Name
(Required)
First
Last
Phone
(Required)
Date of birth ( Birth day promotion)
MM slash DD slash YYYY
Email
(Required)
Medical record section
Have you ever had an allergic reaction to hair perming products?
(Required)
NO
YES please explain below
Other
I understand that brow lamination is NOT recommended for people with following:
(Required)
Alopecia
Conjunctivitis
Currently taking blood thinner
Currently using skin care products or exfoliating products around the eyes contains: Retina A, Glycolic Acid, Salicylic Acid, Alpha Hydroxy Products, Cortisone or Acne Products
Currently or recent Chemotherapy Treatments ( Doctors approval required in either case)
Eczema
Psoriasis Around the Eyes
Recent Eye Surgery
Recent Eye Infection
Recent Microblading ( must be healed over 8 weeks)
Pink eye
Sensitive Skin
Sunburn
Scar tissue in the treatment area
and I hereby certify that none of the above apply to me
Consent section
Although every precaution will be taken to ensure my safety and wellbeing before , during and after the brow lamination process, I am aware of the following information and possible risks.
I understand that during the treatment, despite all precautionary measures, injury is possible.
(Required)
I agree
I understand that some irritation, itching or burning may occur to the skin which comes in contact with the lamination agent.
(Required)
I agree
I understand that it is imperative that I disclose all the information requested on the consent form.
(Required)
I agree
I have cited all conditions and circumstances regarding my health history , medication being taken, and any past reactions to products or medications.
(Required)
I agree
I understand that brow lamination is the process of restructuring the brow hairs to keep them in a desired shape, but it is my responsibility to brush my brows daily to maintain the desired look.
(Required)
I agree
I understand that I should consult with a physician if pregnant or breastfeeding before getting a brow lamination.
(Required)
I agree
I understand that the technician and Beauty Time Centre Inc. , performing the brow lamination will not be held liable for any damages caused to me or my eyebrows by any reason, including allergic reaction, to previous procedures such as previous tint on the brow hair, skin sensitivity and failure to follow the Brow Lamination after care instructions.
(Required)
I agree
I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liability toward my technician and Beauty Time Centre Inc. for any injury or damages incurred due to any misrepresentation of my health
(Required)
I agree
This agreement will remain in effect for this procedure and all future follow-ups conducted by the technician. I understand that this consent agreement is legal and binding. I have read and fully understand all information in this agreement. I am over 18th years of age and consent to the agreement and to the brow lamination procedure, or if I am under 18 years of age, I have had my parent or legal guardian consent to this agreement, and his or her relationship to me is as follows
(Required)
I agree
Name
(Required)
First
Last
signature Date
(Required)
MM slash DD slash YYYY
Signature
(Required)
May we( Beauty Time Centre inc) take your photo?
(Required)
YES
NO
Photo and Video Consent section
PHOTO/VIDEO CONSENT
(Required)
I, the undersigned, give my irrevocable permission to Beauty Time Centre Inc., (BTCI), and/or
parties designated by BTCI, to photograph/video me and use such photograph(s)/video(s) in any
form of media, for any and all promotional/marketing purposes including advertising, display,
audiovisual or exhibition.
I acknowledge that these images may be used on various platforms owned, controlled by, or
associated with BTCI, including social media, the internet, print and any other suitable medium.
I further consent to the use of my name in connection with the photograph(s)/video(s) if needed
by BTCI and/or parties designated by BTCI.
I understand and agree that I will not receive any payment or compensation for my time or
expenses or any royalty for the publication of the photograph(s)/video(s) or the use of my name
and I hereby release BTCI and/or any parties designated by BTCI from any such claims.
My consent and release shall be binding on me and my estate.
I certify that I have read and fully understand this consent and release, and that all questions
pertaining to this consent have been answered to my satisfaction.
I agree to the photo and/or video policy.
Name
(Required)
First
Last
signature Date
(Required)
MM slash DD slash YYYY
Signature
(Required)
Parent or Guardian (if Client is under 18 years of age) Name & signature
parent or Guardian Name
First
Last
signature Date
MM slash DD slash YYYY
Parent or Guardian signature
Recptionist/Technician section
Receptionist/Technician Name
(Required)
First
Last
Signature date
(Required)
MM slash DD slash YYYY
Receptionist/Technician Signature
(Required)
85844
