Brow Henna Consent Form

Come ready so your henna takes evenly:

Complete your patch test at least 48 hours before your first henna service.
Arrive with clean brows — no makeup, oils, or sunscreen on the area.
Skip brow waxing, tinting, or exfoliating the brow area for a few days before.
Pause retinol and exfoliating acids near the brows for a few days before.

For the first 24–48 hours — this is when the stain sets:

Keep brows dry — avoid water, steam, sweat, and swimming for 24–48 hours.
Avoid oil-based cleansers and products on the brows (they fade the stain faster).
Don’t rub or scrub the area; pat gently if needed.
Henna lasts about 2–4 weeks on the skin and up to 6 weeks on the hairs.

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Section A — Client Information

First Name *

Last Name *

Phone *

Email *

Date of Birth *

Today's Date *

City

State

Postal Code

Desired shade

Emergency Contact Name

Emergency Contact Phone

I agree to receive booking confirmations and appointment reminders at my email address above. *

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Section B — Patch Test

Brow henna is a dye and can contain PPD. A patch test is required at least 48 hours before your first henna service to check for allergic reaction. Please confirm below.

Patch test completed — no reaction Need to schedule a patch test Returning client — had henna before with no reaction

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Section C — Photo Release

I consent to before/after photos being taken for use on social media and website.

Name preference for photos

Use my name No name Fictitious name

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Section D — Medical History

List any known allergies (incl. henna, PPD, dyes)

List all current medications

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Section E — Brow Henna Contraindications

Please check any conditions that apply to you. If any box is checked, your technician will review before proceeding.

Known allergy or past reaction to henna, PPD, or hair dye Eczema, dermatitis, or psoriasis in the brow area Broken skin, cuts, or sunburn in the brow area Brow henna, tint, or lamination within the last 2 weeks Recent chemical peel or microdermabrasion in the area (within 2 weeks) Very sensitive skin or history of reaction to tint/henna Recent significant sun exposure or tanning on the brow area Pregnant or breastfeeding

I understand brow henna stains both the hair and skin, that the skin tint typically lasts up to 1–2 weeks and the hair tint 4–6 weeks, that results vary by skin type, and that I should avoid water, cleansers, and exfoliants on the area for 24–48 hours.

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Section F — Client Consent & Signature

Appointment reminders: I consent to receive appointment reminder messages via SMS. Reply STOP to opt out. Promotions: I consent to receive promotional and marketing messages from I Am Beautiful by Mia. Reply STOP to opt out.

By checking the SMS boxes above, you agree that I Am Beautiful by Mia may contact you at the number provided. This is not a condition of service.