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Brow Wax, Tint & Lamination Consent/Release Form

Let us do this part
Today's Date:
Sat May 10 2025 04:12
Practitioner:*
Artist signature:*


Please read and answer
Y
N
COVID-19*
I confirm that I am not presenting any of the symptoms of COVID-19 including but not limited to:

dry cough
runny nose
sore throat
shortness of breath
loss of sense of taste or smell
fever/temperature: 100.0 degrees
 
How did you hear about us?*
 
Consent*
I am not under the influence of alcohol or drugs, and I am voluntarily submitting to receive my service without duress or coercion.
Skin Condition*
I do not have acne, freckles, moles, or sunburn in the area to be serviced that might be agitated by the process.
Medical History*
I acknowledge that I am not pregnant or breastfeeding.
Medical History*
I confirm that I do not have any medical, skin or hair conditions that may interfere with the procedure, application mentioned herein.

I confirm I do not have any of the following skin conditions. If I have any of the following skin conditions, I understand I will not be suitable for the brow wax, lamination and/or tint procedure.

• Psoriasis
• Eczema
• Alopecia
• Sunburn
• Ultra-Sensitive Skin
• Wounds or Scar Tissue in the treatment area
• Infection
• Pimple in the treatment area

I confirm, I have not had any semi-permanent make-up procedure on my Brows for at least 8 weeks.

I confirm, I have not had any skin treatments on my face for at least 4 weeks and have not been on any medication that can affect the skin (such as Accutane) for at least 6 months.
Acknowledgement*
I acknowledge that I have truthfully represented to Brows by Mia & Mia Melville that I am over eighteen (18) years of age. If I am under the age of 18, I acknowledge that I have parent/guardian consent for my services and that this release form is being completed by them.
Risks*
I acknowledge it is not reasonably possible for Brows by Mia & Mia Melville to determine whether I might have an allergic reaction to the waxes, dyes, pigments, tints, solutions or processes used in my services and I agree to accept that such risks are possible.
After Care*
I acknowledge receipt of after care instructions advising me of proper care following my services and recognize the absolute necessity of following those instructions. All questions about my services have been answered to my satisfaction. Brows by Mia & Mia Melville have given me instructions on the after care of my services, and I understand them and will follow them. I agree that the work will be done at my own expense.
Consent*
I acknowledge that the obtaining of my wax, tint and/or lamination services are my choice alone and I consent to the application of waxes, dyes, pigments, solutions or processes, and to any actions or conduct of Brows by Mia & Mia Melville that are reasonably necessary to perform my service.
Waiver, Risks & Consent*
I understand and accept that brow lamination is an Alkaline based perm, so it is very strong. It is not suitable for clients with chemically damaged hair or extremely curly hair, as it can damage it further or cause unpredictable results. If the stylist/artist finds or determines my brow hairs are damaged or is too curly, the stylist/artist may decide to proceed with service and it is at my own risk.

I understand and accept that some mild but normal symptoms may occur depending on the sensitivity of my skin during the procedure and will subside within 24 hours. These symptoms include:

(a) Mild tingling
(b) Slight redness due to brushing brow hairs back and forth
(c) Slightly warm in the area

I acknowledge that I have been advised by Brows by Mia & Mia Melville of the following potential health/medical risks associated with receiving brow lamination and/or tint and still wish to proceed with the procedures mentioned herein:

(a) Allergic reaction symptoms: itching, severe burning, skin flaking or peeling, inflammation, blisters

I understand individual responses to product used for brow lamination, tint and waxes may vary - should a reaction occur; it is my responsibility to seek medical attention at my own expense.

I will advise the brow stylist/artist of any discomfort, irritation, and/or discomfort immediately.

I understand it is my responsibility to follow the aftercare instructions for best results.

I understand that in order to maintain the effects of brow lamination and/or tint, the procedure needs to be re-done every 4-8 weeks (tint) and every 8 weeks (lamination) for maintenance.

I understand that brows may be come unruly if touch ups are not done.

I understand brow lamination will make styling the brows easier but will not eliminate the need for styling. Brushing and/or use of a styling gel may still be required.
Waiver*
I agree to release and forever discharge and forever hold harmless Brows by Mia & Mia Melville from any and all claims, damages, or legal actions arising from or connected in any way with my services, the procedures and conduct used to apply my services and any and all services applied by Brows by Mia & Mia Melville in the future.
Risks*
I acknowledge that the tints, inks, dyes, pigments and solutions used for my services have not been approved by the federal Food and Drug Administration and the health consequences of using these products are unknown.
Consent*
I agree to follow all instructions concerning the care of my services, and that any touch-ups needed because of my own negligence will be done at my own expense.
Video & Photo Release/Waiver*
I release all rights to any photographs and/or video recordings taken of me and the tattoo and give consent in advance to their reproduction in print or electronic form. I hereby grant Brows by Mia & Mia Melville the irrevocable right and permission to use photographs and/or video recordings of me on websites and in publications, social media, promotional flyers, or for any other similar purpose without compensation to me. I understand and agree that such photographs and/or video recordings of me may be placed on the internet. I waive the right to approve the final product. I agree that all such portraits, pictures, photographs, video and audio recordings, and any reproductions thereof, and all plates, negatives, recording tape and digital files are and shall remain the property of Brows by Mia & Mia Melville.
Waiver*
I AGREE TO WAIVE AND RELEASE to the fullest extent permitted by law Brows by Mia & Mia Melville from all liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise from my services, whether caused by the negligence or fault of either the Artist or the Studio, or otherwise.
Attorney Fees*
I agree to reimburse Brows by Mia & Mia Melville for any attorneys' fees and costs incurred in any legal action I bring against either the Artist or the Studio and in which either the Artist or the Studio is the prevailing party. I agree that the courts shall have personal jurisdiction and venue over me and shall have exclusive jurisdiction for the purpose of litigating any dispute arising out of or related to this agreement.
Consent*
I acknowledge that I have been given adequate opportunity to read and understand this document, that any and all of my questions have been answered, that it was not presented to me at the last minute. I understand that by completing this form, a legal contract I am waiving certain rights to recover against Brows by Mia & Mia Melville.
COVID-19*
Brows by Mia & Mia Melville have put in place preventative measures to reduce the spread of COVID-19; however, infection from COVID-19 can happen anywhere and no business can guarantee or completely prevent someone from becoming infected. Further, being in any business could increase your risk of contracting COVID-19.
COVID-19*
To prevent the spread of contagious viruses and to help protect others, I understand that I will have to follow the facility's guidelines. The facilities guidelines can be changed at any time as new information and technology become available.
COVID-19*
I confirm that I have not been in close contact with anyone with COVID-19 symptoms or anyone who has been diagnosed with COVID-19 in the past 14 days.
Acknowledgement & Consent*
I agree to pay Brows by Mia & Mia Melville the total amount due for all services rendered at the time of service.
Acknowledgement & Consent*
I acknowledge that I am aware of Brows by Mia's policy that states there are no refunds on deposits or services.
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 or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or legal guardian is in complete understanding and concurrence with this agreement.
Name:*
Address:
Postcode:
Date of birth:*
If you are under 18 your parent/guardian will be required
Phone #:*
Email:*
Signature:*


Emergency Contact
If something happens, your emergency contact might need to explain your medical history, allergies, or medications.
Name:
Phone #:*
Photo ID*
Please take photo(s) of your government issued photo IDs and related paperwork.