AuraLuxe Patch Test Consent Form

(Valid for 3 Months)

Patch tests are required at least 48 hours before the following treatments: Brow Tint, Lash Tint, Lash Lift, Brow Lamination, Waxing (face/body). Patch tests are valid for 3 months unless your health/products change. If you have any reaction, do not proceed — contact us.

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Patch Test Details

When is your appointment date?

When was this patch test applied?

What products has AuraLuxe Patch tested you for?

Brow code Blue Black tint & 3% Oxident

Brow code Black tint & 3% Oxident

Brow code Light tint & 3% Oxident

Brow code Natural Brown tint & 3% Oxident

Brow code Grey tint & 3% Oxident

AirLift Step 1 & 2 Lash lift/ Brow Lamination solutions

Brow Code Hard Wax & Ital Wax Hard Wax

Ital Wax Roller or Strip Wax

Who applied the patch test

Alexis Courtney

AuraLuxe Staff Member

Where was the patch test applied?”

Behind ear

Inner elbow/forearm

Near brow area

Other (short answer)

Safety Screening

Have you had any allergic reactions to beauty products in the past?

Do you have asthma or breathing difficulties triggered by chemicals/scents?

Do you have autoimmune conditions or are you immunocompromised?

Are you currently taking antibiotics, Roaccutane/isotretinoin, blood thinners, steroid medication/creams, or any medication that affects healing/skin sensitivity?

Skin conditions / sensitivity

Do you have broken skin, sunburn, rash, abrasions, or irritation in the area to be treated?

Have you had a chemical peel, microdermabrasion, microneedling, laser, or strong retinol/acid skincare recently?

Have you used retinol / tretinoin / glycolic / salicylic in the last 7 days on the area being treated?

Eye / lash specific (only relevant to lift/tint/lamination)

Do you currently have any eye infection/irritation (conjunctivitis, stye, watery/itchy eyes)?

Have you had eye surgery in the last 6 months?

Do you wear contact lenses?

Yes

No

If Yes: “You’ll need to remove them for the treatment — do you agree?”

Yes

No

Wax-Specific Screening

Have you ever reacted to waxing (redness lasting >24hrs, swelling, blistering, bruising, skin lifting)?

Are you using or have you recently used:

Acknowledgement

I understand a patch test must be completed at least 48 hours before treatment.

I understand this patch test is valid for 3 months unless my health/products change.

I agree to inform AuraLuxe immediately if I experience any reaction.

I understand if I have any reaction, my treatment may be refused for safety.

Todays Date

Signature

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