Brow Henna Consent Form

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Flawless Permanent Cosmetics HD Henna Brows, Corrective Artistry & Skin Rejuvenation Henna Brow Release and Waiver Client Name __________________________________________________________ Date ___________________________ DOB _______________________ (You must be 18 years of age) Phone (_______)__________________________ Email _____________________________________________________________________ You are receiving a Brow Henna treatment! This includes brow shaping, waxing (if applicable) and application of Brow Henna product. The cost for today’s procedure is $______. If you choose to make an appointment for permanent eyebrows, within 30 days, Flawless will deduct the price you paid today towards the initial price of permanent eyebrows. Only one deduction of Henna Brow treatment and/or discount will be applied if you choose to make an appointment for permanent brows. Multiple discounts will not be applicable Brow Henna is an organic naturally based product with over 99% of the ingredients coming from plants. No peroxides or ammonia are added to this product. Brow Henna contains Henna Plant and may contain some of the following essential oils: Cajuput, Cardamom, Clove, Cypress, Eucalyptus, Lavender, Niaouli, Palma Rosa, Patchouli, Rose Geranium, and Tea Tree. Henna may include the following: Orange Juice, Lemon Juice, Sage, Wild Cherry Powder, black walnut powder, basil, nutmeg, cinnamon, indigo, cassia, buxus dioica, amla, olive oil. Coconut oil and beet powder. Brow Henna does NOT contain the black chemical P.P.D. (Para phenylene Diamine). ______ I am not to my knowledge allergic to any of these 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. ______ .

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The Tarsal Taste of Honey Bees: Behavioral and Electrophysiological Analyses
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