BROW WAIVER Name * First Name Last Name Address Date of Birth Phone (###) ### #### Email * Please tick any of the following that apply: Positive reaction to a patch or sensitivity test (allergy) Previous reaction experienced to the same or similar service in the past Skin conditions such as: Eczema, Dermatitis, Psoriasis, Lesions or Sores, Open wounds Contagious skin diseases (such as, Herpes Simplex, Chicken Pox, or Shingles) Skin trauma, cuts, abrasions, burns and swelling in the immediate area Infections such as Impetigo or Conjunctivitis Chemotherapy Recent operations around eyes, head or face or scar tissue in immediate areas Hypersensitive skin/eyes Alopecia Trichotillomania Any disease/disorder that causes shaking, twitching or erratic movements Steroid or cortizone creams. Please provide medical clearance from dermatologist or doctor Brow growth serums Spray tans or self-tanning lotions Very dry skin Pregnant or lactating Contraceptive Pill or HTR Post Chemotherapy. Please provide medical clearance from your doctor Recent microblading or tattooing service. How long ago: Botox and dermal fillers. How long ago: Anti-acne medications such as Roaccuataine, doxycycline and epiduogel etc. Please List: Anti-aging creams such as Vitamin A, Retinols, AHA’s and BHA’s. Please list: Brow henna application. How long ago: Sunburn How long ago: Other relevant information: Have you had Lash or brow tinting, lash lifting, lash perming, eyelash extension or semi-permanent mascara applied previously? Yes No Information: AGREEMENT: 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). First Name Last Name Date MM DD YYYY Thank you!
