Lash Lift Wavier Form

Name*

First NameLast Name

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

I Authorize Ashley Lynn Esthetics technician to perform the Lash Lift procedure.

I understand the Lash Lift procedure is as follows:

· Bottom lashes are covered with tape

· A silicon pad is glued to the eyelid with a water-soluble glue

· Lashes are lifted on the pad with glue

· The following solutions are applied to the lashes that are lifted on the pad (one at a time for a minimum of 10 minutes and a maximum of 20 minutes): Perm solution, Setting solution, and nourishing Oil

· Lashes are cleaned

· Optional Lash Tint is applied

I understand that it is my responsibility to be still during the procedure and to keep my eyes closed during the process unless otherwise advised. Eyes and skin around them are extremely delicate, and can incur damage, including irritation, burning and allergic reaction to the products used to lift the lashes and/or the tape, anti-wrinkle gel patches or black eyelash tint. These reactions can include anything from mild irritation to a full-blown allergic reaction, even blindness. I have been fully informed as to the methods and procedures concerning the Lash Lift procedure and the risks of the cosmetic procedure I have chosen to have been disclosed to me.

If at anytime I (or the technician) are uncomfortable with the Lash Lift Procedure, I will inform the technician and she will gladly rectify the problem, including ending the session if I (or the technician) wishes. It has been represented to me that NO guarantees, warranties, promises, commitments or other statements as to the results of this treatment have been made. I acknowledge that I have no representation or guarantees, and I am consenting to the procedure at my own risk. All conditions must be revealed or disclosed by me to the technician regarding my health history, medications being taken and any past reactions to products used medications taken. Additional conditions could be discovered during the procedure, which could affect my ability to tolerate the procedure.

I herein sign, release, give up, acquit, and discharge Ashley Lynn Esthetics and or anyone affiliated there to including any partnership, corporations, or company associated with said individual from any claims or damages of ANY nature. I agree to pay any costs of legal services necessary to affect said release. I further agree that this release shall be in contemplation of any possible damages, either known or unknown at the signing of this release and said damages are specifically waived following the signing of this release. I further agree that in the event of any litigations ensues, it shall be placed before the American Arbitration Association or some other such arbitrator for resolution. I agree that in the event a decision is determined in favor of one party over the other, the prevailing party shall be entitled to reasonable attorney fees and costs as set by the arbitrator. I further agree to hold Ashley Lynn Esthetics profession nameless and harmless from any and all damages and liability. I release my Ashley Lynn Esthetics professional from any responsibility for pre-existing conditions I have not revealed or any consequential change to those conditions that arise after the procedure. I accept full responsibility for theses and any other complications, which may arise or result during or following the Lash Lift Procedure(s), which are to be performed at my request.

Please read the following statement and sign and date on the line to indicate that you have read the statement and understand it: I, the client herein signed, certify that I have read and had explained to me and fully understand the above wavier and release form. I certify that I have consulted with Ashley Lynn Esthetics professional. I the client herein signed, for the purposes of documentation, hereby consent to “before and after” photographs, which may or may not be used for the purposes of advertising. I understand there will be NO refunds given for services that were rendered. I understand that my final result may not be what I initially envisioned and understand the health of my natural lashes ultimately determine the result.*

Date*

Date