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Chemical Service Consent Form
You are now being redirected to the necessary forms needed to be filled out for your appointment
Choosing Eyes or Brows?
Eyebrow or Eyelash Tint
Eyebrow or Eyelash Perm
Eyebrow or Eyelash extensions
Have you ever used hair color before?
Have you ever had a allergic reaction to hair color?
Have you ever had a perm before?
Have you ever had an allergic reaction to a perm before?
Do you wear contact lenses?
Are you taking any over-the-counter eyedrops?
Do you have psoriasis?
Any illnesses or conditions of the skin or eyes?
Recent infections within the last six months
Do you wear heavy makeup
Heavy user of ibuprofen or aspirin
If checked off any of the boxes above please explain:
Patch & Waiver Test
I understand that a skin test can determine whether I will suffer a reaction to the products used within 24 hours, but that it is inconclusive whether I will have an allergic reaction at any time in the future. I therefore waiver my option to an allergy test and wish to proceed with treatment.
I have undergone or been offered an allergy test prior to my initial treatment and therefore release polishbyjess from any liability related to allergic reactions to the applied pigments or other products used after the procedure or at a later date
I understand that tanning lashes or brows has some inherent risk of irritation to the orbital area, including either itself, and it could result in stinging or burning, blurry vision, and potential blindness
I understand that if the tinting agent, developer or mixture of both accidentally comes in contact with my eye, that it will be flushed with water or sailing, and I will seek medical attention
I understand that there may be some residual, dark staining left on my skin, following the tinting process of either my lashes browser both this will fade and go away within a short time
I understand that these treatments are not permanent
If I have any concerns, I will address these with my skin care therapist. I give permission to my therapist to perform tinting for perming that we have discussed, and will not hold polishbyjess any liability that may result in damage from the treatment.
I certify that I have read fully and understood the above paragraphs that had a sufficient opportunity for discussion to have any questions answered and understand the procedure, and except the risk I do not hold a practitioner, whose signature appears below responsible for any of the conditions that were present and not disclose at the time of skin care procedure products after care, which may be affected by my treatment during or after
Patches are highly suggested, but I am very humble to know not everybody has the leniency of coming in 48 hours their appointment, and then coming in again for the service, I have made this form to give the consent to release if you choose to opt out of this. There is still the risk of reaction happening. Please be aware.
Clicked Add extensions box?
Eyebrow or Eyelash Extensions
I understand that there are risks associated with having artificial eye or brow hairs applied to and or removed from my eyes or brows
I understand that extensions will be applied to the natural lash or natural brown hairs, as determined by the technician, and will not create an excessive weight that prevents growth of the natural lash or brown hair
I understand that as part of the procedure, I irritation pain, itching, discomfort, and rare cases by or skin infections may occur
I understand the service is nonrefundable
Waiver of liability
Click to agree
I understand that there are risk associated with having extensions applied or removed from existing hair or lash, and that, notwithstanding the Atmos care in the application or removal of these products, there still exist risk associated with the procedure and product itself, which include without lamination irritation, I pain, discomfort, and rare cases blindness, when Improperly handled after treatment as part of his procedure. I understand that a certain amount of adhesive material will be used to attach the individual synthetic hairs to my existing eyelashes or brown hairs. Even though the professional may apply or remove them properly, I understand the adhesive material may become dislodged during or after the procedure, which may irritate eyes or browse further follow up care at my own expense to prevent high damage or eyebrow damage and even skin damage. I also agree to defend the Company polishbyjess from any claims actions, expenses, damages or liabilities, including reasonable attorney fees, which might be asserted against polishbyjess as a result of having this procedure I understand there are no refunds
Care and maintenance
Click to agree
I agree to the following care and maintenance instructions provided by professional for the use and care of my extensions, and that if any follow-up care is required due to my own mistake or negligence or failure to follow instructions, this will be at my own expense and risk I understand that if I do not follow any of the aftercare instructions and may result in damaged who my natural eyelash or eyebrow hairs, and caused to fall out prematurely Knowing this, I agree to this procedure, knowing I will follow after care and follow up with professional for tips for best results I will avoid using waterproof mascara’s or waterproof brow pomade’s. I will not curl touch or pull it any extensions on the eyes or brows. If I experience any itching or irritation, I agreed to consult my professional immediately and have the extensions removed. I agree to not pick or pull my extensions. I understand that I should not attempt to remove them myself and contact professional immediately .
Medical conditions/Informed consent,
Click to agree
I have read and completed the consent form, and it’s entirely in truth of acknowledgment that I have been advised of the potential harm and negative side effects that the extension procedure or removal may cause to those who have specific medical or skin conditions I understand adhesive adhesive remover‘s or a skin, and I mucous membrane irritant, and then rare cases, set persons or maybe allergic or have hypersensitivity to products. I understand that the procedure requires that I lay still for two hours or longer with my eye shot and then if I wear contacts, I must remove the contacts I further state that I have no known medical conditions that might be aggravated by procedure, or any medical condition that would prevent me from complying or heating the professionals, instructions and warnings.
Adding any facials to your service?
If Yes please agree to our terms and conditions
I agree, and are aware that redness or skin irritation may occur
I am not taking Accutane, Retin-A’s, retinoids, AHA’s, BHA‘s or glycolic acid’s that may infuriate with treatment, and if I am, I will mention to my aesthetician
If I have psoriasis, diabetes or dry skin, I will mention to my aesthetician
I am aware that certain medication’s and over-the-counter products can significantly increase the risk of injury combined with services if not mention to aesthetician before treatment
I release any liability for any miscommunication I could have with my aesthetician about my at home, skin care, or current skin conditions or disorders. Hydrofacial may result in redness, or very slight hickey. Bruising, I release any liability that I would project on polishbyjess LLC.
I agree that microcurrent is electro current/EMS TOOL USED ON THE FACE AND WILL MENTION ANY HEALTH ISSUES THAT MAY CONTRADICT. I agree that the electrical currents may activate, said phobias that I have mentally physically or healthwise, and will mention any needed information to my aesthetician, and if I needed service to stop because of panic mode.
I agree that micro dermabrasion is a diamond metal tip mechanical facial device used for exfoliation, and may result in scratching and mention to any information needed to the aesthetician for my at home skin care or other products I may use that will result in a dryer skin environment, presenting me with scratches on my face and not hold polishbyjess LLC liable