Date

Henna Brow Intake Form

Personal Information
Name DOB AGE

Address

Phone Occupation

Email

History
Please circle all that apply.
Skin Disease/Disorder Cardiac Disease Hepatitis
Cancer Hemophilia Inflammatory Disease
Epilepsy/Seizure Disorder Liver Disease Allergies
Low Blood Pressure Botox/Filler Injections Pregnant/Lactating
Fainting Tuberculosis (TB) Blepharoplasty
High Blood Pressure Bleeding Disorders Accutane Use
Migraines/Headaches Trichotillomania Hormone Therapy
Asthma Thyroid Disorder Sickle Cell Anemia
Facelift Autoimmune Disorder Other:
Herpes Simplex Virus Neurological Disorder
Cold Sores/Fever Blisters HIV/AIDS

By signing below, I understand that topical creams, medical conditions, and certain medications can affect the results of
henna. I understand that I can not receive henna if I have certain contraindications and I hereby release "COMPANY
NAME HERE" harmless from and waive on behalf of myself, my heirs, and any personal representatives any and all
causes of action, claims, demands, damages, costs, expenses, and compensation for damages or loss to myself and/or
property that may be caused by any act, or misinformation both intentional or accidentally on this form as well as
failure to follow post-care instructions after my service.

Signature Date
 Date

Henna Brow Consent Form

Personal Information
Name DOB AGE

Address

Phone Occupation

Email

1. ______I agree that I am over the age of 18, am NOT under the influence of alcohol or
drugs, am NOT pregnant or nursing and desire to receive the henna procedure. The general
nature of henna has been explained to me.
2. ______I have been informed of the nature, risks, and possible complications and
consequences of henna. I understand the henna procedure may have known or unknown
complications including but not limited to: infection, scarring, inconsistent color, and
allergic reaction.
3. ______I understand that allergies to the pigment may occur at any time.
4. ______I request the henna procedure and accept the possible complications and
consequences of said procedure and understand that results vary per client.
5. Choose one: I consent______(initial) or waive______(initial) the patch test.
6. ______I understand that if I have any skin treatments including but not limited to laser
hair removal, plastic surgery, or other cosmetic procedures, it may result in adverse
changes to my henna procedure and may not be correctable.
7. ______I have received pre- and post care instructions and I will strictly adhere to such
instructions. I understand that my failure to properly follow pre and post care instructions
may compromise my procedure.

I (print name) consent to allow "COMPANY NAME HERE" to

consult with and evaluate me in order to determine if I am a good candidate for henna. I understand
that photographs and measurements will be taken and kept in my file. I agree that these forms have
been completed truthfully and to the best of my knowledge and abilities. I understand the
contraindications and possible side effects of henna as discussed with staff members of "COMPANY
NAME HERE". Furthermore, I agree to waive all liabilities toward "COMPANY NAME HERE" for any
injury or damages incurred due to my misrepresentation of my health history.

Signature Date