Lash Lift Consent Form

Date*

Date

Full Name*

First NameLast Name

Phone Number*

Area CodePhone Number

E-mail*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How did you hear about Fierce Beauty Boutique?*

Friend/Other

I agree to have an eyelash lift (perm) and/or eyelash tint applied to my natural eyelashes and/or retouched. By signing this agreement, I consent to the procedure of an eyelash perm or eyelash tint by my technician.

I understand there are risks associated with having an eyelash perm and/or eyelash tint. I further understand that as part of the procedure, eye irritation, eye pain, eye itching, discomfort, and in rare cases eye infection or blurriness could occur.

I agree that if I experience any of these medical conditions with my lashes that I will contact my technician and consult a physician at my own expense.

I understand and agree to the care instructions provided by my technician for the use and care of my permed and/or tinted eyelashes. I realize and accept the consequences of failure to adhere to these instructions may cause the eyelashes to not stay permed as long as told.

I understand that all eyelashes are different, and the lift may not work for everybody and there is a risk that the solution will not take. This could indicate your lashes need a longer processing time, or may be too resilient.

I understand and consent to having my eyes closed and covered the entire procedure.

Current use of contact lenses which I agree to remove during application (optional)

yesno

Current use of anything such as oil-containing sunscreen or moisturizers around the eyes?

yesno

Current use of eyedrops of any kind, prescription or over the counter?

yesno

Current allergies or sensitivities to instruments, fumes, tapes, cleaners, eye gel pads, adhesives, and removers that could cause my eyes to water and blink in excess.

yesno

History of recurrent eye or tear duct infections?

yesno

History of dry eyes or Sjorgen’s Syndrome?

yesno

Recent history of Chemotherapy?

yesno

I agree to the following eyelash perm post-op and maintenance instructions:

No water can come in contact with the eye area for 24 hours after the application.

This agreement will remain in effect for this procedure and all future procedures conducted by my technician.

I understand that this consent agreement is legal and binding. I have read and fully understand all information in this agreement. I release my technician from all liability associated with this procedure, which is performed with the utmost attention to safety and proper application using tools and products that the technician has been professionally trained to use.

There are no guarantees for length of time the lashes will stay permed. I understand the aftercare instructions and will do my part to maintain my eyelashes. I understand that there are many factors that may affect the life of the eyelash lift such as water and moisture contact, weather conditions, and activities involving exposure to high temperatures.

I understand and acknowledge I must give a minimum of 24 hours notice of cancellation. If I fail to give a 24 hours notice, this could result in forfeiture of any prepaid services, vouchers, or online scheduling privileges.

You are paying for artist time, product and other expenses used to provide you with a service. No refunds will be given for services or products. Should you have any issues to occur with your lashes, please contact me within 72 hours of your appointment to discuss your concerns.

As a courtesy to Fierce Beauty Boutique, and in order to efficiently accommodate all clients, a cancellation fee of 50% service value is required. Cancellations without 24 hours notice will be charged this fee. No shows are also subject to a 50% fee to be charged to the card on file.

Signature

Lash Lift Agreement & Consent Form