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Forms

MIRAGE Salon & MedSpa

Brow Lamination & Tinting Consent Form

CONSENT AND LIABILITY RELEASE

TO BROW LAMINATION & TINTING OF EYEBROWS 

Patient Information:

SECTION 1: ACKNOWLEDGMENTS AND AGREEMENTS

SECTION 2: RISKS

I acknowledge and accept the following risks:

SECTION 3: HEALTH QUESTIONNAIRE  

To perform the Brow Lamination procedure in a safe manner, please answer the following health questions truthfully. We will keep all information disclosed in a confidential manner and will use it only for purposes of determining whether you are an ideal candidate for this procedure.

Do you currently have and/or have had in the past, and/or have you experienced any of the following:
Have you consumed drugs or alcohol in the last 24 hours?
Yes
No
Did you in the last 14 days undergo surgery, in which you were you exposed to radiation, or any other medical interventions?
Yes
No
Have you ever been allergic to, or have had an allergic reaction to perm solution?
Yes
No
Have you ever been allergic to, or have had an allergic reaction to Hair Dye?
Yes
No

SECTION 4: USE OF LIKENESS AND RELEASE 

By participating as a client, I permit, authorize, and license the technician(s) and the Business and their employees, officers, directors, and agents of each and all of them ("Authorized Persons"), to display, publicly perform, exhibit, transmit, broadcast, reproduce, record, photograph, digitize, modify, alter, edit, adapt, create derivative works, exploit, sell, rent, license, otherwise use, and permit others to use my image, likeness, and appearance, and all materials created by or on behalf of my participation that incorporates any of the foregoing ("Materials") on a perpetual basis throughout the world and in any medium or format whatsoever now existing or hereafter created for publicity, advertising, and marketing purposes, and for any purpose they deem reasonably appropriate, without further consent from or royalty, payment, or other compensation to me. 


I agree that all right, title and interest in and to all such Materials is the exclusive property of the Authorized Persons. I understand that the Authorized Persons may keep or use the Materials now and in the future. I understand that although the Authorized Persons will endeavor to use my image, likeness, and appearance in accordance with standards of good judgment, they cannot warrant or guarantee that any further dissemination of my image, likeness, and appearance will be subject to their supervision or control. Accordingly, I release the Authorized Persons from all liability or responsibility that may arise from the acts that I have authorized or consented to in this Section.  

SECTION 5: GENERAL RELEASE AND WAIVER  

I recognize and acknowledge that there are certain risks of personal injury or property damage related to my participation as a client, and I voluntarily agree to fully assume all of these risks, regardless of severity, that I may sustain as a result of participating in any and all activities connected with or associated with the application by the technician of brow lamination and/or coloring to my eyebrows using the Brow Lamination technique, including, but not limited to, injuries, damages and losses arising out of negligent supervision, tort, contract, products, or any other theory of recovery.  


I, for myself and my heirs, assigns, personal representatives, and next of kin, expressly waive and release any and all claims, now known or hereafter known, against the Business, and their employees, officers, directors, and agents of each and all of them (collectively, "Releasees"), on account of personal injury or property damage arising out of or attributable to my participation as a client, whether arising out of the negligence of any Releasees or otherwise. I covenant not to make or bring any such claim against any Releasee, and forever release and discharge all Releasees from liability under such claims.  


All matters arising out of or relating to this waiver and release shall be governed by and construed in accordance with the internal laws of Canada without giving effect to any choice or conflict of law provision or rule (whether of Canada or any other jurisdiction). Any claim or cause of action arising under this waiver and release may be brought only in the federal and Provincial courts located in Canada and I consent to the exclusive jurisdiction of such courts.  


I understand that this waiver and release is intended to be as broad and inclusive as permitted by law and that if any portion hereof is held invalid, I agree that the balance shall continue in full legal force and effect. I further agree that if this waiver and release is not valid in Canada, it shall be construed as a covenant not to sue anytime, anywhere and for any reason.  

SECTION 6: CONSENT

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