Date *

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Name *

First Name

Last Name

Phone Number *

(###)

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Email *

Address *

Date of Birth *

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PREVIOUS DISCOMFORT, STINGING OR ADVERSE REACTION

Please check any that apply:

Skin Disorder

Eye Infections

Watery Eyes

Bell's Palsy

Inflammation of the skin

Recent eye surgery

Hay Fever

Previous reactions to eye treatments

Eye Disease

Blepharitis

Allergies

Contact Lens

Allergies to Acetone

Allergies to Latex/Band Aids

Allergies to glue/bonding agents/adhesives

Are you pregnant/lactating?

Are you on the contraceptive pill?

Are you taking HRT?

Any medications:

Other relevant information:

Have you had brow tinting, Lash Lifting, Lash perming, Eyelash extensions or semi-permanent mascara applied previously?

Yes

No

Information/Last done on:

AGREEMENT: I request and consent to these procedures being carried out today without undergoing a sensitivity patch test. The sensitivity test, which if conducted may indicate my sensitivity / allergy to the products. I understand the contents of this form and take full responsibility for my actions, thus absolving all other parties of their responsibilities, if any, associated with the supply of the products and services(s). *

print full name

Date

MM

DD

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PHOTO RELEASE: I give my permission to use my image, and/or appearance as such may be embodied in any pictures, photos, video recordings, digital images, and the like, taken or made on behalf of Mai Berg Artistry, LLC. I agree that Mai Berg Artistry, LLC has complete ownership of such pictures, etc., including the entire copyright, and may use them for any purpose consistent with Mai Berg Artistry, LLC mission. These uses include, but are not limited to illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications, advertisements, and any promotional or educational materials in any medium now known or later developed, including the Internet. I acknowledge that I will not receive any compensation, etc. for the use of such pictures, etc., and hereby release Mai Berg Artistry, LLC and its agents and assigns from any and all claims which arise out of or are in any way connected with such use. *

I have read and understood this consent and release.