Loading...

TINTING PATCH TEST AND INFORMED CONSENT FORM

I have had a patch test at least 24 hours before my tinting service and see no signs of irritation or allergy.

I understand that I may still experience allergic reaction, sensitivity, irritation, and or temporary staining from the service.

I acknowledge that a Brows on Upper 15th representative has given me information on the nature of the tinting procedure.

I hereby consent to a Brows on Upper 15th representative performing the tinting procedures on me.

In consideration of their doing so, I discharge Brows on Upper 15th, its owners and employees of and from all claims arising out of the performance of the said treatment procedures.

I accept responsibility for any consequences that might stem from my decision to have tinting work done.

I understand that I may experience allergic reaction, sensitivity, irritation, and or temporary staining from the service. Allergic reaction is rare but can be severe. I understand that any person can develop an allergy to any substance at any time, so prior tintings are not a guarantee that no allergy exists.

 

(rev 12/2008)

Brows On Upper 15th * 2540 15th Street * Denver, Colorado 80211 720-855-3021

First Client's Name

First Name*

Middle Name

Last Name*

Phone*
First Client's Date of Birth*
First Client's Signature*
Second Client's Name

First Name*

Middle Name

Last Name*
Second Client's Date of Birth*
Third Client's Name

First Name*

Middle Name

Last Name*
Third Client's Date of Birth*
Fourth Client's Name

First Name*

Middle Name

Last Name*
Fourth Client's Date of Birth*
Fifth Client's Name

First Name*

Middle Name

Last Name*
Fifth Client's Date of Birth*
Sixth Client's Name

First Name*

Middle Name

Last Name*
Sixth Client's Date of Birth*
Seventh Client's Name

First Name*

Middle Name

Last Name*
Seventh Client's Date of Birth*
Eighth Client's Name

First Name*

Middle Name

Last Name*
Eighth Client's Date of Birth*
Ninth Client's Name

First Name*

Middle Name

Last Name*
Ninth Client's Date of Birth*
Tenth Client's Name

First Name*

Middle Name

Last Name*
Tenth Client's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
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.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
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