Loading...

The Threading Studio

Lash Lift / Tint
Client Consent Form
 

 COVID 19 SCREENING

MANDATORY FOR CLIENTS: As per the CDC (Center of Communicable Disease) guidance, The Threading Studio is required to follow all the guidelines given.  The business has the right to screen and refuse services if anything related to COVID 19 for the safety of the public, staff, and business.

I am willing to take a temperature check during my visit to the salon before the services are started.  


If you have  following symptoms before appointment according to https://gov.texas.gov/uploads/files/organization/opentexas/OpenTexas-Checklist-Massage-Personal-Care-Beauty-Service-Customers.pdf , you agree not to come to the salon and inform us.  


 Fever 100 degrees Fahrenheit and above

Cough                                                                 
Shortness of breath                                          
Chills                                                                   
Loss of taste or smell                                       
Headache                                                           
Diarrhea                                                             
Muscle pain                                                        
Sore Throat                                                        
Vomiting                                                             
Wheezing                                                            
Cold                                                                      
Allergies                     

You agree not to seek the service if you or anyone in your household  


 Is an active COVID-19 patient or has had a fever of 100 or above within 14 days of the service day.
 Traveled outside the United States in the past 14 days to countries that have been affected by COVID-19.
Traveled domestically within the United State by commercial airline, bus, or train within the past 14 days.
Have worked in the COVID 19 frontlines, facilities, or locations?     

You agree and understand to the following   


             

 To wear mask for the duration of the service except for the services which needs mask off.
The CDC recommends social distancing of at least 6 feet, and that this is not possible during the services we provide.
You agree to knowingly and willingly consenting to these procedures for yourself / your child with the full understanding and disclosure of such risks and alternatives associated with the COVID-19 pandemic, and all your  questions were answered to your satisfaction.      

If you did not initial for any of the above covid-19 symptoms then do not proceed and cancel this form and inform us and  visit your medical provider ASAP.

I request & consent to these procedures being carried out today without undergoing a sensitivity patch. The sensitivity test, which if conducted, may indicate my sensitivity or allergy to the products, I agree to contact my treatment provider in the first onset of any reactions that may occur. I understand the contents of this form and have been truthful with all my answers. I 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. 


 

 

First clients Name

First Name*

Last Name*

Phone*
First clients Age Acknowledgment*
First clients Date of Birth*
I certify that I am 18 years of age or older
First clients Information

DAte Of Birth : Please select in this order 1st year. 2nd Month and 3rd day *
First clients Signature*
Second clients Name

First Name*

Last Name*
Second clients Date of Birth*
Second clients Information

DAte Of Birth : Please select in this order 1st year. 2nd Month and 3rd day *
Third clients Name

First Name*

Last Name*
Third clients Date of Birth*
Third clients Information

DAte Of Birth : Please select in this order 1st year. 2nd Month and 3rd day *
Fourth clients Name

First Name*

Last Name*
Fourth clients Date of Birth*
Fourth clients Information

DAte Of Birth : Please select in this order 1st year. 2nd Month and 3rd day *
Fifth clients Name

First Name*

Last Name*
Fifth clients Date of Birth*
Fifth clients Information

DAte Of Birth : Please select in this order 1st year. 2nd Month and 3rd day *
Sixth clients Name

First Name*

Last Name*
Sixth clients Date of Birth*
Sixth clients Information

DAte Of Birth : Please select in this order 1st year. 2nd Month and 3rd day *
Seventh clients Name

First Name*

Last Name*
Seventh clients Date of Birth*
Seventh clients Information

DAte Of Birth : Please select in this order 1st year. 2nd Month and 3rd day *
Eighth clients Name

First Name*

Last Name*
Eighth clients Date of Birth*
Eighth clients Information

DAte Of Birth : Please select in this order 1st year. 2nd Month and 3rd day *
Ninth clients Name

First Name*

Last Name*
Ninth clients Date of Birth*
Ninth clients Information

DAte Of Birth : Please select in this order 1st year. 2nd Month and 3rd day *
Tenth clients Name

First Name*

Last Name*
Tenth clients Date of Birth*
Tenth clients Information

DAte Of Birth : Please select in this order 1st year. 2nd Month and 3rd day *
clients Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
Have you ever had any of the following or adverse reactions to any listed below:
Skin Disorders*
No
Yes
Inflammation of Skin*
No
Yes
Eye Disease*
No
Yes
Eye Infections*
No
Yes
Eye Surgery*
No
Yes
Blephartitis*
No
Yes
Watery Eyes*
No
Yes
Hay Fever*
No
Yes
Allergies*
No
Yes
Bell's Palsy*
No
Yes
Contact Lenses*
No
Yes
Allergies to Latex*
No
Yes
Allergies to Acetone*
No
Yes
Pregnant/Lactating*
No
Yes
Taking HRT*
No
Yes
Use of Contraception*
No
Yes
Allergies to glues, adhesives, bonding agents*
No
Yes
Previous reactions to eye treatments*
No
Yes

If yes to any above, please explain:
Current Medications/Supplements:

enter medication details
Previously received lash/brow tinting, lash perming, lash extensions or semi-permanent mascara?*
No
Yes
If yes select applicable ones
Tinting
Lash Perm / Lift
Lash Extensions
Semi-permanent mascara
if yes did you get reaction to any of the treatment
No
yes

If there was reaction, please explain

Did you seek medical advice from a doctor or specialist as a result of the reaction and if so, what was the advice and/or treatment?:
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

DAte Of Birth : Please select in this order 1st year. 2nd Month and 3rd day *
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!