Brow Lamination & Tint Consultation + Consent Form
Client Information
Full Name
Date of Birth
Phone Number
Email
Emergency Contact Name & Number:
How did you hear about us?
Referral by Someone Social Media Website Walk-in Other
Medical History
Please check all that apply:
Pregnant or nursing Allergies (including latex, hair dye, adhesives)Allergies (including hair dye or tint) Eczema, psoriasis, or dermatitis near the eye or brow area Sensitive skin or eyes Eye infections (conjunctivitis, styes, etc.) Hormonal conditions Diabetes Autoimmune disorders Currently using any prescribed topical medications Other medical conditions we should know
Service History & Contraindications
Have you had a brow lamination or tint before?
Yes No If yes, when?
Are you currently using any of the following?
Retinol or Retin-A AHA/BHA products Accutane (must be off for 6+ months) Steroid creams Lash/brow serums (Latisse, etc.)
Do you have any of the following conditions near the brow area?
Cuts or abrasions Recent sunburn Inflammation, swelling, or open wounds Recent cosmetic tattoo (microblading)
Treatment Goals & Expectations
What are you hoping to achieve with today’s service?
Are there any specific concerns or sensitivities I should be aware of?
Client Acknowledgement & Legal Consent
I, the undersigned, acknowledge that brow lamination involves the use of chemical solutions to straighten and set the brow hairs into a desired shape, and tinting involves applying a semi-permanent dye to darken or enhance the brows. I understand and agree to the following:
A patch test may be offered but does not guarantee avoidance of allergic reactions.
The products used can cause skin or eye irritation, redness, or allergic responses in rare cases.
I have disclosed all relevant medical history, allergies, medications, and sensitivities.
I understand that results may vary depending on individual hair texture, skin type, and aftercare practices.
I agree to follow all aftercare instructions, including avoiding makeup, water, sweating, or brow manipulation for at least 24 hours post-treatment.
I release Derma Direction and my esthetician from liability should any adverse reactions occur, provided procedures were performed properly and professionally.
Yes, I voluntarily give my full and informed consent to receive brow lamination and/or tinting services at Derma Direction.
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