Due to some recent scheduling changes and home repairs I’m taking a brief hiatus from taking appointments until August 1st, 2015.

Select one of the following options to be taken to the form’s text:

Waxing/Tinting

Lash Extensions

Photo Release (optional)


Client Release Form: Waxing

Name [FORM FIELD]*

Birthdate [FORM FIELD]*

Phone [FORM FIELD]*

Email [FORM FIELD]

Street Address [FORM FIELD]

Please answer the following questions. All of the information you provide will be kept confidential.

Do you currently suffer from any of the following medical conditions:

Active lesion(s) of Herpes Simplex I or II on or near the area being waxed? Y/N

Sunburn on or near the area being waxed? Y/N

Diabetes? Y/N

Psoriasis or Eczema on or near the area being waxed? Y/N

Redness, rashing or abraded skin on or near the area being waxed? Y/N

Have you used any of the following products or services recently?

Isotretinoin (aka Accutane, Amnesteem, Claravis, Isotroin, Roaccutane, or Sotret)? Y/N

How recently? *

  • Currently
  • Within the last 2 months
  • Greater than 2 months ago

Retin-A or Renova? Y/N

How recently? *

  • Currently
  • Within the last 2 months
  • Greater than 2 months ago

Blood-thinners? Y/N

How recently? *

  • Currently
  • Within the last 2 months
  • Greater than 2 months ago

Any other prescription-strength acne medications? Y/N

How recently? *

  • Currently
  • Within the last 2 months
  • Greater than 2 months ago

Microdermabrasion? Y/N

How recently? *

  • Currently
  • Within the last 2 months
  • Greater than 2 months ago

Chemical Peel? Y/N

How recently? *

  • Currently
  • Within the last 2 months
  • Greater than 2 months ago

Bleaching Agents for hair or skin? Y/N

How recently? *

  • Currently
  • Within the last 2 months
  • Greater than 2 months ago

By signing below, I confirm that I do not suffer from the above-mentioned contraindications for my services today. I am aware that regarding Herpes Simplex types I and II, it has been advised that waxing services may cause an outbreak to re-surface. I certify that all the information above is correct and hereby give my consent for a waxing treatment. I also understand that it is my responsibility to inform Jessica Myer, Owner and proprietor dba The Jade Room, of any changes pertaining to the information I have provided on this form. I have read the above contraindications for the services I am about to receive and do therefore agree to waive all liabilities toward Jessica Myer, Owner and proprietor dba The Jade Room, for injury or damages.

Signature
[DRAW FIELD]*


Client Release Form: Lash Extensions

Name [FORM FIELD]*

Birthdate [FORM FIELD]*

Phone [FORM FIELD]*

Email [FORM FIELD]

Street Address [FORM FIELD]

Please answer the following questions. All of the information you provide will be kept confidential.

Please select any of the following medical conditions you currently have or have recently experienced:

Seasonal allergies Y/N

Allergies to topical ingredients (especially cyanoacrylate) Y/N

Alopecia Y/N

How recently? *

  • Currently
  • Within the last month
  • Longer than 1 month ago

Redness, rashing or abraded skin on or near your eyes Y/N

How recently? *

  • Currently
  • Within the last month
  • Longer than 1 months ago

Cancer Y/N

How recently? *

  • Currently
  • Within the last 2 months
  • Greater than 2 months ago

Demodex Folliculorum Y/N

How recently? *

  • Currently
  • Within the last 2 months
  • Greater than 2 months ago

Non-functioning tear ducts Y/N

How recently? *

  • Currently
  • Within the last 2 months
  • Greater than 2 months ago

Select the following products or services you have used recently:

Lasik surgery Y/N

How recently? *

  • Currently
  • Within the last 2 months
  • Greater than 2 months ago

Permanent eye makeup Y/N

How recently?*

  • Currently
  • Within the last 2 months
  • Greater than 2 months ago

Eye-lift Y/N

How recently? *

  • Currently
  • Within the last 2 months
  • Greater than 2 months ago

Micro-dermabrasion/Chemical peel Y/N

How recently? *

  • Currently
  • Within the last 2 months
  • Greater than 2 months ago

Retin-A, Accutane, or other acne medications Y/N

How recently? *

  • Currently
  • Within the last 2 months
  • Greater than 2 months ago

By signing below, I am agreeing to the following statements and conditions: I assume full responsibility for myself or the minor in my care. Additionally, I certify that all the information above is correct and hereby give my consent to receive eyelash extensions. I hold harmless Minkys, Lash Stuff, and Jessica Myer, Owener and proprietor dba The Jade Room for any and all injury, loss or damage to person or personal property to the fullest extent of the law. I understand this is an eyelash extension procedure involving appling one single extension to my natural lash using a cyanoacrylate-based adhesive. I understand that I must keep my eyes closed during this procedure. I understand as part of the procedure eye irritation, allergies, eye pain, eye itching, discomfort, and in rare instances, eye infection may occur. I understand that in order to ensure the longest, lasting lashes possible I should avoid rubbing and pulling eye lashes, mascara not designed for eyelash extension, water and steam for the next 24 hours. I also understand that it is my responsibility to inform Jessica Myer, Owner and proprietor dba The Jade Room, of any changes pertaining to the information I have provided on this form before preceding any future appointments.

Signature
[DRAW FIELD]*


Client Photo Release Form

I, [FORM FIELD]*, hereby authorize Jessica Myer, owner/proprietor dba The Jade Room to use my likeness in a photograph in any and all publications related to said business. I authorize the editing, copying, altering, exhibiting and publishing of any and all photographs taken during my appointment today.

By signing this form, I acknowledge that the use of my likeness in a photograph is being granted as part of a promotional discount. I acknowledge that since my participation in The Jade Room’s temporary promotional pricing is voluntary, I will not receive any financial compensation. Additionally, I waive any right to royalty or other compensation arising or related to the use of this/these photograph/s.

By signing this form, I hereby hold harmless and release and forever discharge Jessica Myer, owner/proprietor dba The Jade Room from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

I am at least 18 years of age and am competent to contract in my own name. I have read this release before signing below and I fully understand the contents, meaning, and impact of this release

By signing below, I acknowledge all of the above statements

[DRAW FIELD]*

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