Brows Intake and Consent Form

Lamination | Waxing | Tint

What A Lamination Is

Brow lamination involves the perming of your eyebrow hairs to provide a fuller and darker more even look.

Acknowledgment of Risks

By checking the boxes and initialing below, I acknowledge and accept the following:

1. Potential Risks

✦Brow lamination, tint, and wax involve the use of perming and tinting solutions. While these treatments are safe for most clients, there is always a possibility of an allergic reaction, irritation, redness, bumps, itching, burning, swelling, dryness, over-processing, or premature brow hair loss.

✦These reactions are not indicative of improper application or malpractice but are dependent on the client's unique skin, hair, and health conditions.

✦If you have dry, damaged, brittle brow hairs, or any skin condition, brow lamination and tint may worsen these conditions.

✦ Waxing for hair removal, particularly on the face carries risks. These risks may include redness, bruising, and lifting of the skin. These conditions may be exacerbated by the use of certain pharmaceuticals and cosmetics, particularly those for anti-aging and anti-acne treatments. Examples of these are retinoid, Retin-A, Renova, Accutane, and AHA’s like glycolic acid. Face waxing should be avoided when using these products.

✦Certain prescription medications may aggravate the skin when waxed, particularly those causing photo-sensitivity (sensitive to sunlight). Examples of these are many antibiotics, such as tetracycline, and blood thinners such as Warfarin, which may cause an individual to bruise easily.

✦ Clients who are receiving aesthetic and dermatological peeling treatments may also experience redness and skin lifting from waxing and therefore should avoid waxing while undergoing such treatments.

✦ The use of tanning booths can also contraindicate waxing. Waxing should not be done 24 hours before or after tanning. It should also not be done on an area that still shows an erythema (redness) from tanning.

✦ Because the fields of pharmacology and dermatology are continually changing and expanding, there may be products and drugs that cause negative reactions to waxing that have yet to be documented.

✦ Brow lamination is not recommended for pregnant or breastfeeding women.

I confirm that I have read, understood, and accept the potential risks

2. Product Ingredients

The solutions used in this procedure may include, but are not limited to:

✦ Ammonium thioglycolate, Cetearyl Alcohol, Lauryl Alcohol, Ceteareth-20, Ceteareth-30, Tetrasodium EDTA, Sodium Hydroxide, and Sodium Sulfite

3. How Long it Lasts

The minimum or maximum duration of the Brow Lamination cannot be determined with certainty. The duration depends on several factors, including but not limited to:

✦ How hard you scrub your face

✦ The type of makeup remover or cleanser you use

✦ Sun exposure

✦ Sunscreen use

✦ Your hair’s natural growth and shedding cycle

✦ The use of harsh products, such as AHAs, BHAs, retinol, or any chemical peels applied to the area

I confirm that I have read, understood, and accept that the duration of the brow lamination varies

Aftercare

✦ First 24 hours: No water, steam, sauna, heavy exercise, shampoos, makeup, or skincare products on or near the Brow Lamination area.

✦ First 48 hours: Do NOT use makeup remover or oils on top or close to the Brow

✦ I understand Brow Lamination, Brow correction is a process of reconstructing the brow hairs to keep them in a desired shape, but it is my own responsibility to brush them daily to achieve the desired look.

I confirm that I have read, understood, and accept the aftercare

5. Optional Patch Test

There are a small number of individuals who may have an allergic reaction to tints, hair dyes, and other chemical treatments. It is only in rare situations that the reaction can be severe. If you've ever gotten a rash from an allergic reaction to hair dye containing para-phenylenediamine (PPD), then you may also develop an allergic rash to lash or brow dyes and should not use them.

We offer a complimentary patch test service for all clients. Please request an additional patch test if you would like to check your sensitivity, which should be performed 48 hours prior to your appointment. We thank you for your cooperation to ensure your comfort and safety.

Would you like the optional Patch Test?

Initials

Please read each statement, initial in each box, and sign this document to accept your acknowledgement and agreement of the following:

I affirm that I am 18 years of age or older, and competent to sign this release on my own behalf. I have read and fully understand and accept this agreement and all information detailed throughout this consent and intake form. I understand the service and accept the risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold the technician and or Kate Aglaia Aesthetics owner responsible for any of my conditions that weren’t disclosed at the time of the skin care service, which may be affected by the treatment performed. I understand that this agreement will remain in effect for this procedure and all future procedures conducted by my technician. Although it is impossible to list every potential risk and complication, I have been informed of possible risks and complications. I have also, to the best of my knowledge, given an accurate account of my medical history, including known allergies or prescription drugs or products I am currently ingesting or using topically. I understand and accept the nature and purpose of the products to be used in this service has been explained to me, along with the risks and hazards involved.

Signature

To be signed by parent/guardian if the participant is under 18

Today's Date

Full Name

Date of Birth

Month

Day

Year

Phone

Address

Any medication?

Are you pregnant or lactating?

Do you have any allergies to latex, adhesives, glues, bonding agents, acetone, or hair dyes?

Have you had any previous reactions to the treatment you are receiving today?

If yes, please explain

Do you participate in vigorous aerobic activity or sports?:

Have you received Botox, Restylane, or Collagen injections in the last 6 months?:

Any other relevant information we should be aware of?

How did you hear about us?

I hereby consent to and authorize Kate Aglaia Aesthetics to perform a brow treatment

I give Kate Aglaia Aesthetics permission to take photos of my treatment for before-and-after comparison, educational purposes, marketing (social media), and documentation.

I understand and accept that there are risks associated with having my brows laminated, waxed, or tinted. I understand that no warranty, guarantee, or assurance has been made to me as a result of the brow technique and that the final result cannot be guaranteed as each skin type and hair is unique. I further acknowledge that, as part of the procedure other potential risks can occur. I agree that if I experience any conditions during or after the procedure, I will notify Kate Aglaia Aesthetics and consult a physician at my own expense.

I fully release my technician & Kate Aglaia Aesthetics from any liability related to this procedure, during & after its completion. The procedure will be performed with utmost safety & proper technique, using tools & products the technician is trained in.

Signature

Today's Date

I understand payment is due in full at the time of service. Cancellations or rescheduling must be made 48 hours in advance, or a 50% charge applies. No-shows are charged 75%. Late arrivals (10+ mins) incur a no-show fee and must reschedule.