Henna Brow Consent Form

Patient's Name

First name

Last name

Date of Birth

Month

Day

Year

Is this your first time having a henna brow service?

Yes

Do you have any known allergies?

Yes

Consent Agreement

I understand that Henna is temporary; not permanent, and it may fade in less than three weeks. I understand that on rare occasions allergic reactions may still occur after providing all my known allergens beforehand. I confirm that there are no guarantees, warranties, or promises regarding the result of the procedure. I understand that I need to follow the instructions provided to me by the professional before, during, and after the procedure. I understand that a photo may need be taken for before and after documentation. I understand that there will be no refunds issued if the procedure requires after-care expenses and/or unsatisfactory results. I have read and reviewed this form thoroughly before submission to the best of my knowledge and ability. I confirm that all information in this document is accurate and true.

Use of photographs for educational and publishing materials:

I consent to have my photographs taken before, during, and after my treatment. I understand that using these materials will not fully reveal my identity. The purpose of this is for education and possible marketing.

I do not consent to have my photographs taken before, during, and after my treatment.

I agree to the terms and conditions above.

Signature

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Date Signed

If minor, please provide the additional information:

Parent/Guardian Name

Relationship (Father, Mother, etc.)

Date Signed

Chemical Peel Consent

I hereby give my consent for the treatment of chemical peel to be done to my face and/or areas of my body. The procedure, benefits, and risks of chemical peels have been explained to me. I understand and acknowledge the risks and benefits. I understand that this treatment is a program. It may require sessions or cycles in order to reach my desired results. It has been explained to me that this treatment is an outpatient procedure that can be done in clinics or offices. It has been explained to me that during treatment, I might feel a burning sensation that would last for 10-20 minutes upon application of the chemical to my skin. I understand that after a few days, the area where the chemical peel was applied may darken and/or shall become glossy or shiny and peel or flake. These days might prevent me from visiting work or going to places where I will be exposed to sunlight. In this regard, I shall comply with the strict requirements given to me by my esthetician. I understand that there are no guarantees that the desired result will be achieved. I understand that complications may occur, although this is rare in case such happens, it must be treated immediately by my doctor. Complications may appear as: Allergic reactions due to medications or with the chemical peel or both, keloids or thick scars, increased or decreased pigmentation, sensitivity to the wind or sun.

Use of photographs for educational and publishing materials:

I do not consent to have my photographs taken before, during, and after my treatment.

First name

Last name

Phone

Signature

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Date

Month

Day

Year