Loading...

CONSENT AND LIABILITY RELEASE TO BROW HENNA & COLORING OF EYEBROWS

I agree to having the service of brow henna and eyebrow colouring performed on me by Permanent Beauty by Ieva.

SECTION 1: ACKNOWLEDGMENTS AND AGREEMENTS

Please initial before each statement to accept your acknowledgement and agreement to the following:

That I have been given a copy of this Consent and Liability Release (the "Release") prior to the Henna Brow technique being performed on me.

That it is my responsibility to advise the technician of any concerns I may have before participating as a client/customer and having this service performed on me, even though I may have written it down in this Release. 

That I have read and accepted the risks set forth in Section 2. I have been given the opportunity to ask questions, either by written or verbal communication, prior to signing this Release. As a result, I have sufficient information to give this informed consent. 

That I must complete the Health Questionnaire in Section 3 before I can have this service performed on me. I understand my participation as a client may be refused depending on my responses, including but not limited to, if I am pregnant, nursing or if I have any allergies or contraindications. 

That no warranty or guarantee has been made to me as a result of the Brow Henna technique, and that the final result cannot be guaranteed as each skin type is unique. 

SECTION 2: RISKS

I acknowledge and accept the following risks:

  1. During the treatment, despite all precautionary measures, injury is possible. I will not hold the technician or business performing this service on me responsible in any way for any damages or issues that may arise as a result of having the Brow Henna procedure performed on me.
  2. Despite application of the most advanced and top ingredients, an allergic reaction is possible.
  3. The minimum or maximum duration of the colour from the procedure cannot be determined with certainty.
  4. The technician and the business performing the service on me will not liable for any damages caused to me or my eyebrows in any way caused by any reason, including my failure to follow the Brow Henna Aftercare Instructions.
    As part of the aftercare, apply a moisturizing product developed specifically for Brow Henna to prolong the color of the stain.

SECTION 3: HEALTH QUESTIONNAIRE

To perform the Brow Henna procedure in a safe manner, please answer the following health questions truthfully. We will keep all information disclosed in a confidential manner and will use it only for purposes of determining whether you are an ideal candidate for this procedure.

SECTION 4: USE OF LIKENESS AND RELEASE

By participating as a client, I permit, authorize, and license the technician(s) and the Business and their employees, officers, directors, and agents of each and all of them ("Authorized Persons"), to display, publicly perform, exhibit, transmit, broadcast, reproduce, record, photograph, digitize, modify, alter, edit, adapt, create derivative works, exploit, sell, rent, license, otherwise use, and permit others to use my image, likeness, and appearance, and all materials created by or on behalf of my participation that incorporates any of the foregoing ("Materials") on a perpetual basis throughout the world and in any medium or format whatsoever now existing or hereafter created for publicity, advertising, and marketing purposes, and for any purpose they deem reasonably appropriate, without further consent from or royalty, payment, or other compensation to me.

I agree that all right, title and interest in and to all such Materials is the exclusive property of the Authorized Persons. I understand that the Authorized Persons may keep or use the Materials now and in the future. I understand that although the Authorized Persons will endeavor to use my image, likeness, and appearance in accordance with standards of good judgment, they cannot warrant or guarantee that any further dissemination of my image, likeness, and appearance will be subject to their supervision or control. Accordingly, I release the Authorized Persons from all liability or responsibility that may arise from the acts that I have authorized or consented to in this Section.

SECTION 5: GENERAL RELEASE AND WAIVER

I recognize and acknowledge that there are certain risks of personal injury or property damage related to my participation as a client, and I voluntarily agree to fully assume all of these risks, regardless of severity, that I may sustain as a result of participating in any and all activities connected with or associated with the application by the technician of brow henna and/or coloring to my eyebrows using the Brow Henna technique, including, but not limited to, injuries, damages and losses arising out of negligent supervision, tort, contract, products, or any other theory of recovery.

I, for myself and my heirs, assigns, personal representatives, and next of kin, expressly waive and release any and all claims, now known or hereafter known, against the Business, and their employees, officers, directors, and agents of each and all of them (collectively, "Releasees"), on account of personal injury or property damage arising out of or attributable to my participation as a client, whether arising out of the negligence of any Releasees or otherwise. I covenant not to make or bring any such claim against any Releasee, and forever release and discharge all Releasees from liability under such claims.

All matters arising out of or relating to this waiver and release shall be governed by and construed in accordance with the internal laws of Canada without giving effect to any choice or conflict of law provision or rule (whether of Canada or any other jurisdiction). Any claim or cause of action arising under this waiver and release may be brought only in the federal and Provincial courts located in Canada and I consent to the exclusive jurisdiction of such courts.

I understand that this waiver and release is intended to be as broad and inclusive as permitted by law and that if any portion hereof is held invalid, I agree that the balance shall continue in full legal force and effect. I further agree that if this waiver and release is not valid in Canada, it shall be construed as a covenant not to sue anytime, anywhere and for any reason.

I HAVE READ THE INFORMATION IN THIS WAIVER THOROUGHLY. I UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT. I HAVE THE CAPACITY TO PROVIDE INFORMED CONSENT AND I AM SIGNING THIS WAIVER AND RELEASE FREELY AND VOLUNTARILY.

Today's Date: August 8, 2020

First Client Name

First Name*

Last Name*

Phone*
First Client Date of Birth*
First Client Information

Do you suffer from the following diseases or are you taking any of these medications? 

Hemophilia*
No
Yes
Diabetes mellitus (diabetes)*
No
Yes
Hepatitis A, B, C, D, E, F*
No
Yes
HIV +*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Allergies*
No
Yes
Autoimmune diseases*
No
Yes
Are you prone to herpes?*
No
Yes
Infectious diseases / high fever*
No
Yes
Epilepsy*
No
Yes
Cardiovascular problems*
No
Yes
Are you taking medication for blood thinning (anticoagulants)?*
No
Yes
Are you pregnant?*
No
Yes
Are you taking any medications on daily basis?*
No
Yes
Do you have a pacemaker?*
No
Yes
Do you have problems with healing of wounds?*
No
Yes
Have you tinted your eyebrows in the last 6 months?*
No
Yes
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you in the last 14 days undergo surgery, in which you were you exposed to radiation, or any other medical interventions?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to henna?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to Hair Dye?*
No
Yes
First Client Signature*
Second Client Name

First Name*

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

Do you suffer from the following diseases or are you taking any of these medications? 

Hemophilia*
No
Yes
Diabetes mellitus (diabetes)*
No
Yes
Hepatitis A, B, C, D, E, F*
No
Yes
HIV +*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Allergies*
No
Yes
Autoimmune diseases*
No
Yes
Are you prone to herpes?*
No
Yes
Infectious diseases / high fever*
No
Yes
Epilepsy*
No
Yes
Cardiovascular problems*
No
Yes
Are you taking medication for blood thinning (anticoagulants)?*
No
Yes
Are you pregnant?*
No
Yes
Are you taking any medications on daily basis?*
No
Yes
Do you have a pacemaker?*
No
Yes
Do you have problems with healing of wounds?*
No
Yes
Have you tinted your eyebrows in the last 6 months?*
No
Yes
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you in the last 14 days undergo surgery, in which you were you exposed to radiation, or any other medical interventions?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to henna?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to Hair Dye?*
No
Yes
Second Client Signature*
Third Client Name

First Name*

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

Do you suffer from the following diseases or are you taking any of these medications? 

Hemophilia*
No
Yes
Diabetes mellitus (diabetes)*
No
Yes
Hepatitis A, B, C, D, E, F*
No
Yes
HIV +*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Allergies*
No
Yes
Autoimmune diseases*
No
Yes
Are you prone to herpes?*
No
Yes
Infectious diseases / high fever*
No
Yes
Epilepsy*
No
Yes
Cardiovascular problems*
No
Yes
Are you taking medication for blood thinning (anticoagulants)?*
No
Yes
Are you pregnant?*
No
Yes
Are you taking any medications on daily basis?*
No
Yes
Do you have a pacemaker?*
No
Yes
Do you have problems with healing of wounds?*
No
Yes
Have you tinted your eyebrows in the last 6 months?*
No
Yes
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you in the last 14 days undergo surgery, in which you were you exposed to radiation, or any other medical interventions?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to henna?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to Hair Dye?*
No
Yes
Third Client Signature*
Fourth Client Name

First Name*

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

Do you suffer from the following diseases or are you taking any of these medications? 

Hemophilia*
No
Yes
Diabetes mellitus (diabetes)*
No
Yes
Hepatitis A, B, C, D, E, F*
No
Yes
HIV +*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Allergies*
No
Yes
Autoimmune diseases*
No
Yes
Are you prone to herpes?*
No
Yes
Infectious diseases / high fever*
No
Yes
Epilepsy*
No
Yes
Cardiovascular problems*
No
Yes
Are you taking medication for blood thinning (anticoagulants)?*
No
Yes
Are you pregnant?*
No
Yes
Are you taking any medications on daily basis?*
No
Yes
Do you have a pacemaker?*
No
Yes
Do you have problems with healing of wounds?*
No
Yes
Have you tinted your eyebrows in the last 6 months?*
No
Yes
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you in the last 14 days undergo surgery, in which you were you exposed to radiation, or any other medical interventions?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to henna?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to Hair Dye?*
No
Yes
Fourth Client Signature*
Fifth Client Name

First Name*

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

Do you suffer from the following diseases or are you taking any of these medications? 

Hemophilia*
No
Yes
Diabetes mellitus (diabetes)*
No
Yes
Hepatitis A, B, C, D, E, F*
No
Yes
HIV +*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Allergies*
No
Yes
Autoimmune diseases*
No
Yes
Are you prone to herpes?*
No
Yes
Infectious diseases / high fever*
No
Yes
Epilepsy*
No
Yes
Cardiovascular problems*
No
Yes
Are you taking medication for blood thinning (anticoagulants)?*
No
Yes
Are you pregnant?*
No
Yes
Are you taking any medications on daily basis?*
No
Yes
Do you have a pacemaker?*
No
Yes
Do you have problems with healing of wounds?*
No
Yes
Have you tinted your eyebrows in the last 6 months?*
No
Yes
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you in the last 14 days undergo surgery, in which you were you exposed to radiation, or any other medical interventions?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to henna?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to Hair Dye?*
No
Yes
Fifth Client Signature*
Sixth Client Name

First Name*

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

Do you suffer from the following diseases or are you taking any of these medications? 

Hemophilia*
No
Yes
Diabetes mellitus (diabetes)*
No
Yes
Hepatitis A, B, C, D, E, F*
No
Yes
HIV +*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Allergies*
No
Yes
Autoimmune diseases*
No
Yes
Are you prone to herpes?*
No
Yes
Infectious diseases / high fever*
No
Yes
Epilepsy*
No
Yes
Cardiovascular problems*
No
Yes
Are you taking medication for blood thinning (anticoagulants)?*
No
Yes
Are you pregnant?*
No
Yes
Are you taking any medications on daily basis?*
No
Yes
Do you have a pacemaker?*
No
Yes
Do you have problems with healing of wounds?*
No
Yes
Have you tinted your eyebrows in the last 6 months?*
No
Yes
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you in the last 14 days undergo surgery, in which you were you exposed to radiation, or any other medical interventions?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to henna?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to Hair Dye?*
No
Yes
Sixth Client Signature*
Seventh Client Name

First Name*

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

Do you suffer from the following diseases or are you taking any of these medications? 

Hemophilia*
No
Yes
Diabetes mellitus (diabetes)*
No
Yes
Hepatitis A, B, C, D, E, F*
No
Yes
HIV +*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Allergies*
No
Yes
Autoimmune diseases*
No
Yes
Are you prone to herpes?*
No
Yes
Infectious diseases / high fever*
No
Yes
Epilepsy*
No
Yes
Cardiovascular problems*
No
Yes
Are you taking medication for blood thinning (anticoagulants)?*
No
Yes
Are you pregnant?*
No
Yes
Are you taking any medications on daily basis?*
No
Yes
Do you have a pacemaker?*
No
Yes
Do you have problems with healing of wounds?*
No
Yes
Have you tinted your eyebrows in the last 6 months?*
No
Yes
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you in the last 14 days undergo surgery, in which you were you exposed to radiation, or any other medical interventions?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to henna?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to Hair Dye?*
No
Yes
Seventh Client Signature*
Eighth Client Name

First Name*

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

Do you suffer from the following diseases or are you taking any of these medications? 

Hemophilia*
No
Yes
Diabetes mellitus (diabetes)*
No
Yes
Hepatitis A, B, C, D, E, F*
No
Yes
HIV +*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Allergies*
No
Yes
Autoimmune diseases*
No
Yes
Are you prone to herpes?*
No
Yes
Infectious diseases / high fever*
No
Yes
Epilepsy*
No
Yes
Cardiovascular problems*
No
Yes
Are you taking medication for blood thinning (anticoagulants)?*
No
Yes
Are you pregnant?*
No
Yes
Are you taking any medications on daily basis?*
No
Yes
Do you have a pacemaker?*
No
Yes
Do you have problems with healing of wounds?*
No
Yes
Have you tinted your eyebrows in the last 6 months?*
No
Yes
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you in the last 14 days undergo surgery, in which you were you exposed to radiation, or any other medical interventions?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to henna?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to Hair Dye?*
No
Yes
Eighth Client Signature*
Ninth Client Name

First Name*

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

Do you suffer from the following diseases or are you taking any of these medications? 

Hemophilia*
No
Yes
Diabetes mellitus (diabetes)*
No
Yes
Hepatitis A, B, C, D, E, F*
No
Yes
HIV +*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Allergies*
No
Yes
Autoimmune diseases*
No
Yes
Are you prone to herpes?*
No
Yes
Infectious diseases / high fever*
No
Yes
Epilepsy*
No
Yes
Cardiovascular problems*
No
Yes
Are you taking medication for blood thinning (anticoagulants)?*
No
Yes
Are you pregnant?*
No
Yes
Are you taking any medications on daily basis?*
No
Yes
Do you have a pacemaker?*
No
Yes
Do you have problems with healing of wounds?*
No
Yes
Have you tinted your eyebrows in the last 6 months?*
No
Yes
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you in the last 14 days undergo surgery, in which you were you exposed to radiation, or any other medical interventions?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to henna?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to Hair Dye?*
No
Yes
Ninth Client Signature*
Tenth Client Name

First Name*

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

Do you suffer from the following diseases or are you taking any of these medications? 

Hemophilia*
No
Yes
Diabetes mellitus (diabetes)*
No
Yes
Hepatitis A, B, C, D, E, F*
No
Yes
HIV +*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Allergies*
No
Yes
Autoimmune diseases*
No
Yes
Are you prone to herpes?*
No
Yes
Infectious diseases / high fever*
No
Yes
Epilepsy*
No
Yes
Cardiovascular problems*
No
Yes
Are you taking medication for blood thinning (anticoagulants)?*
No
Yes
Are you pregnant?*
No
Yes
Are you taking any medications on daily basis?*
No
Yes
Do you have a pacemaker?*
No
Yes
Do you have problems with healing of wounds?*
No
Yes
Have you tinted your eyebrows in the last 6 months?*
No
Yes
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you in the last 14 days undergo surgery, in which you were you exposed to radiation, or any other medical interventions?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to henna?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to Hair Dye?*
No
Yes
Tenth Client Signature*
Client 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*
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*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Do you suffer from the following diseases or are you taking any of these medications? 

Hemophilia*
No
Yes
Diabetes mellitus (diabetes)*
No
Yes
Hepatitis A, B, C, D, E, F*
No
Yes
HIV +*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Allergies*
No
Yes
Autoimmune diseases*
No
Yes
Are you prone to herpes?*
No
Yes
Infectious diseases / high fever*
No
Yes
Epilepsy*
No
Yes
Cardiovascular problems*
No
Yes
Are you taking medication for blood thinning (anticoagulants)?*
No
Yes
Are you pregnant?*
No
Yes
Are you taking any medications on daily basis?*
No
Yes
Do you have a pacemaker?*
No
Yes
Do you have problems with healing of wounds?*
No
Yes
Have you tinted your eyebrows in the last 6 months?*
No
Yes
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you in the last 14 days undergo surgery, in which you were you exposed to radiation, or any other medical interventions?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to henna?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to Hair Dye?*
No
Yes
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!