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Henna Patch Test

Let us do this part
Today's Date:
Thu May 2 2024 06:38
Practitioner:*
Artist signature:*


Please read and answer
*
Supercilium Brow Henna is 88% natural henna and vegan. Supercilium Brow Henna contains a small amount of PPD which is under the limit allowed by the FDA for hair dyes and cosmetics. \r\n\r\nBlonde Henna. Ingredients Sodium Carbonate Peroxide, Cellulose Gum, Magnesium Sulfate, Citric Acid, Lawsonia Inermis Extract (henna), Silica, Sodium Lauryl Sulfate, p-Aminophenol, 4-Amino-2-Hydroxytoluene, Simmondsia Chinensis Oil (jojoba seed oil), Aloe Barbadensis Leaf Extract, 1-Naphthol, P-Phenylenediamine Hcl, 4-Chlororesorcinol\r\n\r\nLight Brown Henna. Ingredients Sodium Carbonate Peroxide, Cellulose Gum, Lawsonia Inermis Extract (henna), Citric Acid, Magnesium Sulfate, Silica, P-Phenylenediamine Hcl, Sodium Lauryl Sulfate, p-Aminophenol, 4-Chlororesorcinol, 4-Amino-2-Hydroxytoluene, 1-Naphthol, Aloe Barbadensis Leaf Extract, Simmondsia Chinensis Oil (jojoba seed oil)\r\n\r\nMedium Brown Henna. Ingredients Sodium Carbonate Peroxide, Cellulose Gum, Lawsonia Inermis Extract (henna), Magnesium Sulfate, Citric Acid, P-Phenylenediamine Hcl, Silica, p-Aminophenol, Sodium Lauryl Sulfate, 4-Chlororesorcinol, Simmondsia Chinensis Oil (jojoba seed oil), Aloe Barbadensis Leaf Extract, 1-Naphthol, 4-Amino-2-Hydroxytoluene\r\n\r\nDark Brown Henna. Ingredients Sodium Carbonate Peroxide, Cellulose Gum, P-Phenylenediamine Hcl, Lawsonia Inermis Extract (henna), Citric Acid, Magnesium Sulfate, Silica, p-Aminophenol, Sodium Lauryl Sulfate, 1-Naphthol, 4-Amino-2-Hydroxytoluene, 4-Chlororesorcinol, Simmondsia Chinensis Oil (jojoba seed oil), Aloe Barbadensis Leaf Extract
Allergy*
By checking this box: I agree I am not, to my knowledge, allergic to any of the above listed ingredients. I understand and acknowledge that I should avoid Henna if I have G6PD deficiency, been advised to avoid Fava beans, Quinine, are extremely anemic, have serious citrus allergies or essential oil allergies.
Patch Test*
By checking this box: Client holds artist and Southern Brows LLC harmless and absolves artist and Southern Brows LLC from all liability resulting from allergic reactions to henna products. Pigments being used have a low probability of allergic reaction but cannot absolutely rule out the possibility of allergic reaction. The efficacy of a patch test has been discussed with the client.
Sterile*
Artist only utilizes sterilized, disposable equipment to minimize the risk of infection or contamination. In addition, artist has received training in appropriate sanitation and hygiene techniques prior to performing any procedures. While artist believes the risk of infection from our procedures is extremely small, the possibility of such an occurrence cannot be totally precluded. Accordingly, by checking this box, client understands and accepts this risk and releases artist and Southern Brows, LLC from any and all liability related to the subject procedure, expecting instances involving gross negligence.
Disputes*
By checking this box: I agree that artist is limited to the cost of the procedure performed. In the event of disputes that cannot be amicably resolved, the artist, with Southern Brows LLC and client agree to binding arbitration to resolve any disputes at client’s expense.
Consent*
By checking this box: I certify this form has been fully explained to me and that I have read it or it has been read to me. I understand its contents. As evidence of my signature below, I understand and agree to the above conditions upon which artist will be performing.\r\n
If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.
Client Information
I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement.
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You must be 18 or older
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Photo ID*
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