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Please read and fill out this “Disclosure & Release Agreement” completely, making certain that you understand all information provided, and that your information is correct.

You have the right to be informed so that you may make the decision whether or not to undergo the procedure, after knowing the risks and hazards involved. This disclosure is simply an effort to make you better informed so you may give, or withhold, your consent to the procedure

Although every precaution will be made to ensure your safety and well being before, during and after your tinting application, please be aware of the possible risks below. By initialing below this field you are agreeing to fully read each statement, and agree to continue with service:

  • I understand tinting eyelashes or eyebrows can have some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging or burning, blurry vision and potentially blindness should tinting agent enter into the eye.
  • I understand that some irritation, itching, or burning may occur to the skin which comes in contact with the tinting agent
  • I understand that there may be some residual dark staining left on the skin following the tinting process of either my lashes, brows, or both. This will fade and go away within a short time
  • I understand that, while every attempt will be made to provide me with my chosen color, everyone's hair aborbs color differently and my final results may not be the color I initially wanted
  • I understand that over the course of several weeks, the tint will gradually lighten and fade. Re-tinting will be required to keep the new color fresh. Most clients need to re-tint every 4-6 weeks
  • I consent to "before and after" photographs for the purpose of documentation, potential advertising, and promotional purposes
  • I will accurately answer the questions below, including all known allergies, previous reactions to treatments, prescription drugs and/or any products I am currently ingesting or using topically
  • I will fully read the information given. By typing my initial's in the box below I agree that if I have any concerns, I will address them with my esthetician. Additionally, I hereby give my permission to my esthetician to perform the tinting application we have discussed and will hold him/her and his/her staff harmless from any liability that may result from this treatment



By typing my full name in the box below, I agree that this form constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I hereby agree that I understand the procedure and accept the risks and will inform the esthetician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. This agreement will remain in effect for this procedure and all future follow-ups conducted by the esthetician. I am willingly agreeing to not hold my esthetician responsible for any of my conditions that were present, but not disclosed in this form, which may be affected by the treatment preformed. *

First Client's Name
First Name*
Last Name*
Phone*
First Client's Date of Birth*
Date of Birth
First Client's Information
Have you ever had your brows or lashes tinted before?*
No
Yes
Did you have an adverse reaction to previous tinting?*
No
Yes
If you have had an adverse reaction to previous tinting, please explain:
Have you ever used hair color before?*
No
Yes
Have you ever had an allergic reaction to hair color?*
No
Yes
Do you wear contacts?*
No
Yes
Are you currently pregnant or breastfeeding?*
No
Yes
Please select any of the following if applicable: *
Highly sensitive skin
Diabetes, lupus, or any auto-immune disease
Recent Chemotherapy
Recent permanent makeup(PMU) procedure
None of the above
If you selected any of the following above, please describe: *
What over-the-counter or prescription skin care products are you currently using?
Please list any illnesses or conditions you are currently being treated by a physician for:
Please list any medications you are currently taking, including but not limited to over the counter herbs, vitamins, and/or supplements:
Please list any allergies you may have: *
First Client's Signature*
Second Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Second Client's Information
Have you ever had your brows or lashes tinted before?*
No
Yes
Did you have an adverse reaction to previous tinting?*
No
Yes
If you have had an adverse reaction to previous tinting, please explain:
Have you ever used hair color before?*
No
Yes
Have you ever had an allergic reaction to hair color?*
No
Yes
Do you wear contacts?*
No
Yes
Are you currently pregnant or breastfeeding?*
No
Yes
Please select any of the following if applicable: *
Highly sensitive skin
Diabetes, lupus, or any auto-immune disease
Recent Chemotherapy
Recent permanent makeup(PMU) procedure
None of the above
If you selected any of the following above, please describe: *
What over-the-counter or prescription skin care products are you currently using?
Please list any illnesses or conditions you are currently being treated by a physician for:
Please list any medications you are currently taking, including but not limited to over the counter herbs, vitamins, and/or supplements:
Please list any allergies you may have: *
Third Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Third Client's Information
Have you ever had your brows or lashes tinted before?*
No
Yes
Did you have an adverse reaction to previous tinting?*
No
Yes
If you have had an adverse reaction to previous tinting, please explain:
Have you ever used hair color before?*
No
Yes
Have you ever had an allergic reaction to hair color?*
No
Yes
Do you wear contacts?*
No
Yes
Are you currently pregnant or breastfeeding?*
No
Yes
Please select any of the following if applicable: *
Highly sensitive skin
Diabetes, lupus, or any auto-immune disease
Recent Chemotherapy
Recent permanent makeup(PMU) procedure
None of the above
If you selected any of the following above, please describe: *
What over-the-counter or prescription skin care products are you currently using?
Please list any illnesses or conditions you are currently being treated by a physician for:
Please list any medications you are currently taking, including but not limited to over the counter herbs, vitamins, and/or supplements:
Please list any allergies you may have: *
Fourth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Fourth Client's Information
Have you ever had your brows or lashes tinted before?*
No
Yes
Did you have an adverse reaction to previous tinting?*
No
Yes
If you have had an adverse reaction to previous tinting, please explain:
Have you ever used hair color before?*
No
Yes
Have you ever had an allergic reaction to hair color?*
No
Yes
Do you wear contacts?*
No
Yes
Are you currently pregnant or breastfeeding?*
No
Yes
Please select any of the following if applicable: *
Highly sensitive skin
Diabetes, lupus, or any auto-immune disease
Recent Chemotherapy
Recent permanent makeup(PMU) procedure
None of the above
If you selected any of the following above, please describe: *
What over-the-counter or prescription skin care products are you currently using?
Please list any illnesses or conditions you are currently being treated by a physician for:
Please list any medications you are currently taking, including but not limited to over the counter herbs, vitamins, and/or supplements:
Please list any allergies you may have: *
Fifth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Fifth Client's Information
Have you ever had your brows or lashes tinted before?*
No
Yes
Did you have an adverse reaction to previous tinting?*
No
Yes
If you have had an adverse reaction to previous tinting, please explain:
Have you ever used hair color before?*
No
Yes
Have you ever had an allergic reaction to hair color?*
No
Yes
Do you wear contacts?*
No
Yes
Are you currently pregnant or breastfeeding?*
No
Yes
Please select any of the following if applicable: *
Highly sensitive skin
Diabetes, lupus, or any auto-immune disease
Recent Chemotherapy
Recent permanent makeup(PMU) procedure
None of the above
If you selected any of the following above, please describe: *
What over-the-counter or prescription skin care products are you currently using?
Please list any illnesses or conditions you are currently being treated by a physician for:
Please list any medications you are currently taking, including but not limited to over the counter herbs, vitamins, and/or supplements:
Please list any allergies you may have: *
Sixth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Sixth Client's Information
Have you ever had your brows or lashes tinted before?*
No
Yes
Did you have an adverse reaction to previous tinting?*
No
Yes
If you have had an adverse reaction to previous tinting, please explain:
Have you ever used hair color before?*
No
Yes
Have you ever had an allergic reaction to hair color?*
No
Yes
Do you wear contacts?*
No
Yes
Are you currently pregnant or breastfeeding?*
No
Yes
Please select any of the following if applicable: *
Highly sensitive skin
Diabetes, lupus, or any auto-immune disease
Recent Chemotherapy
Recent permanent makeup(PMU) procedure
None of the above
If you selected any of the following above, please describe: *
What over-the-counter or prescription skin care products are you currently using?
Please list any illnesses or conditions you are currently being treated by a physician for:
Please list any medications you are currently taking, including but not limited to over the counter herbs, vitamins, and/or supplements:
Please list any allergies you may have: *
Seventh Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Seventh Client's Information
Have you ever had your brows or lashes tinted before?*
No
Yes
Did you have an adverse reaction to previous tinting?*
No
Yes
If you have had an adverse reaction to previous tinting, please explain:
Have you ever used hair color before?*
No
Yes
Have you ever had an allergic reaction to hair color?*
No
Yes
Do you wear contacts?*
No
Yes
Are you currently pregnant or breastfeeding?*
No
Yes
Please select any of the following if applicable: *
Highly sensitive skin
Diabetes, lupus, or any auto-immune disease
Recent Chemotherapy
Recent permanent makeup(PMU) procedure
None of the above
If you selected any of the following above, please describe: *
What over-the-counter or prescription skin care products are you currently using?
Please list any illnesses or conditions you are currently being treated by a physician for:
Please list any medications you are currently taking, including but not limited to over the counter herbs, vitamins, and/or supplements:
Please list any allergies you may have: *
Eighth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Eighth Client's Information
Have you ever had your brows or lashes tinted before?*
No
Yes
Did you have an adverse reaction to previous tinting?*
No
Yes
If you have had an adverse reaction to previous tinting, please explain:
Have you ever used hair color before?*
No
Yes
Have you ever had an allergic reaction to hair color?*
No
Yes
Do you wear contacts?*
No
Yes
Are you currently pregnant or breastfeeding?*
No
Yes
Please select any of the following if applicable: *
Highly sensitive skin
Diabetes, lupus, or any auto-immune disease
Recent Chemotherapy
Recent permanent makeup(PMU) procedure
None of the above
If you selected any of the following above, please describe: *
What over-the-counter or prescription skin care products are you currently using?
Please list any illnesses or conditions you are currently being treated by a physician for:
Please list any medications you are currently taking, including but not limited to over the counter herbs, vitamins, and/or supplements:
Please list any allergies you may have: *
Ninth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Ninth Client's Information
Have you ever had your brows or lashes tinted before?*
No
Yes
Did you have an adverse reaction to previous tinting?*
No
Yes
If you have had an adverse reaction to previous tinting, please explain:
Have you ever used hair color before?*
No
Yes
Have you ever had an allergic reaction to hair color?*
No
Yes
Do you wear contacts?*
No
Yes
Are you currently pregnant or breastfeeding?*
No
Yes
Please select any of the following if applicable: *
Highly sensitive skin
Diabetes, lupus, or any auto-immune disease
Recent Chemotherapy
Recent permanent makeup(PMU) procedure
None of the above
If you selected any of the following above, please describe: *
What over-the-counter or prescription skin care products are you currently using?
Please list any illnesses or conditions you are currently being treated by a physician for:
Please list any medications you are currently taking, including but not limited to over the counter herbs, vitamins, and/or supplements:
Please list any allergies you may have: *
Tenth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Tenth Client's Information
Have you ever had your brows or lashes tinted before?*
No
Yes
Did you have an adverse reaction to previous tinting?*
No
Yes
If you have had an adverse reaction to previous tinting, please explain:
Have you ever used hair color before?*
No
Yes
Have you ever had an allergic reaction to hair color?*
No
Yes
Do you wear contacts?*
No
Yes
Are you currently pregnant or breastfeeding?*
No
Yes
Please select any of the following if applicable: *
Highly sensitive skin
Diabetes, lupus, or any auto-immune disease
Recent Chemotherapy
Recent permanent makeup(PMU) procedure
None of the above
If you selected any of the following above, please describe: *
What over-the-counter or prescription skin care products are you currently using?
Please list any illnesses or conditions you are currently being treated by a physician for:
Please list any medications you are currently taking, including but not limited to over the counter herbs, vitamins, and/or supplements:
Please list any allergies you may have: *
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.


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 Date of Birth*
Date of Birth
Parent or Guardian's Information
Have you ever had your brows or lashes tinted before?*
No
Yes
Did you have an adverse reaction to previous tinting?*
No
Yes
If you have had an adverse reaction to previous tinting, please explain:
Have you ever used hair color before?*
No
Yes
Have you ever had an allergic reaction to hair color?*
No
Yes
Do you wear contacts?*
No
Yes
Are you currently pregnant or breastfeeding?*
No
Yes
Please select any of the following if applicable: *
Highly sensitive skin
Diabetes, lupus, or any auto-immune disease
Recent Chemotherapy
Recent permanent makeup(PMU) procedure
None of the above
If you selected any of the following above, please describe: *
What over-the-counter or prescription skin care products are you currently using?
Please list any illnesses or conditions you are currently being treated by a physician for:
Please list any medications you are currently taking, including but not limited to over the counter herbs, vitamins, and/or supplements:
Please list any allergies you may have: *
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.


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