Lash Lift Waiver

LASH LIFT &/OR TINT

DISCLOSURE & WAIVER FORM
A lash lift and tint is a popular beauty treatment that enhances the natural appearance of lashes without the need for extensions. The process involves lifting the lashes from the root and setting them in place with a perming solution. This gives the lashes a more upright and lifted look. After the lifting process, a semi-permanent dye (optional) is applied to the lashes to add color and definition. The entire process usually takes around 45 minutes to an hour. The effects of a lash lift and tint can last anywhere from 6-8 weeks depending on the individual's lash growth cycle. The treatment is relatively low maintenance and allows clients to wake up with perfectly curled and tinted lashes. It can also help to make the eyes appear more open and awake, giving the face an overall more youthful and refreshed appearance.
Full Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Phone Number

Area CodePhone Number
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
How did you hear about us?*
Emergency Contact Name & Phone Number*
Have you ever had a Lash Lift?*

YesNo
If yes, have you ever had an adverse reaction?
If yes, please explain
Have you ever had an allergic reaction to perming products?*
if yes, please explain
Do you wear contact lenses?*

YesNo
Do you have frequent eye irritation, itching, or watery eyes?*

YesNo
Are you pregnant or breastfeeding?*

YesNo
Do you have, or are you being treated for any kind of eye injury?*
if yes, please explain
Please list medication or vitamins you're presently taking
Do you presently have or previously had any of the following:(Select all that apply)*

Eye Infections/disordersRecent Eye SurgeryVery sensitive eyesHay fever suffer/water eyesConjunctivitisStyeDry eyes or Sjorgen's SyndromUsing prescribed medicated eye dropsMedication - Thyroxin (could prevent lashes from curling)Contact lenses (must be removed)Allergy to dye or tintSeasonal AllergiesAllergy to GlycerinAllergy to Surgical Glue or Nail GlueDiabetesTake medications that can cause hair lossRecent Eye InfectionPermanent EyemakeupNoneOther
Please list any illness or condition you are currently being treated by a physician.
I UNDERSTAND AND I AGREE TO THE FOLLOWING COMPLETELY (PLEASE INITIAL EACH STATEMENT)
Initial* I agree to have a Lash Lift with or without Dye applied to my eyelashes and or retouched.
Initial* I choose to waive the patch test and accept full responsibility for any reaction which might occur. (If patch test is requested, it must be done within 48 hrs before the scheduled appointment).
Initial* I understand that Lash lift & Dye has some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging or burning and blurry should the perming products enter into the eye.
Initial* I understand that if the Lash Lift & Dye products accidentally comes into contact with my eye, my eye will be flushed with water and medical attention may be required.
Initial* I understand that it is imperitive that I disclose all of the information requested on the disclosure & waiver form.
Initial* I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications.
Initial* I understand that additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure.
Initial* I agree that if I experience any ill effects with my lashes that I will contact the technician that performed this procedure.
Initial* I understand and consent to having my eyes closed and covered for the duration of the procedure.
Initial* I understand that I need to keep my eyelashes free of water for 48 hours after the Lash Lift &/or Dye.
Initial* I understand and agree to the after-care instructions provided by the technician. I realize and accept the consequences of failure to adhere to these instructions.
Photo/Video Consent
I hereby grant Admired Radiance,LLC the full right to take, publish and reproduce photographs/videos of me, my face,my body, both before and after this procedure, for any advertising education, or other purposes whatsoever, including the right to retouch these photographs as deemed necessary. I further expressly assign any copyright in these photographs to my esthetician and her business. I grant my consent to my esthetician to use my image and likeness as contained in these photographs for any advertising or other purposes, along with any comments I may provide. Please use images with the following:
I grant consent with my own nameI grant consent with no nameI DO NOT grant consent
Pre & Post Care

To ensure the best possible results, please read and follow the Pre & Post Care instructions listed below.
Prior to your appointment, we recommend the following:
- Do not wear water-proof mascara for 24 hours ahead of your appointment
- a patch test may be performed if you have a history of allergy to adhesives or perming solutions. Patch tests should be done 48 hours prior to your first appointment.
On the day of your first appointment:
- Do not wear mascara
- Do not have a spray tan
- Avoid applying oil products on your lashes or around your eyes
Post Care, we recommend the following:
- Do not get lashes wet or use mascara for the first 24 hours.
- Avoid steam, saunas and swimming for the first 48 hours.
- Avoid touching, rubbing or introducing foreign bodies or contaminants into the eye area.
- Ensure the lashes are not disturbed or manipulated into different positions (e.g. when sleeping, cleansing the face, applying moisturizer or cosmetics).
- Do not use lash curlers
- Avoid strong sunlight or UV light if tinted.
- Use aftercare serums to maintain healthy and beautiful lashes
- Follow-up appointments should be scheduled within 6-8 weeks
I certify that I have read and fully understand the above paragraphs, that I have had sufficient opportunity for discussion and to ask questions, and that I hereby consent to the procedure(s) described above.

I confirm to the best of my knowledge that the information I have provided is accurate and complete. I have not withheld any information that may be relevant to my treatment and/or the results thereof. I am aware that there are often inherent risks associated with skin care services, and that the services I am about to receive could have unfavorable results including, but not limited to allergic reaction, irritation, burning, redness, scarring, soreness, etc. By Signing below, I further agree that I will not hold Admired Radiance,LLC responsible should there be any unfavorable outcome or result.

I authorize Admired Radiance to charge my credit card for any cancellations (24 hours prior) or no show fee to my appointment. I understand that my information will be saved to file for future transactions on my account.
Client Signature*

Clear
Signature of Parent/Guardian (if under 18)

Clear
Name of Parent/Guardian & Phone Number
Should be Empty:

LASH LIFT &/OR TINT

I UNDERSTAND AND I AGREE TO THE FOLLOWING COMPLETELY (PLEASE INITIAL EACH STATEMENT)

Initial* I agree to have a Lash Lift with or without Dye applied to my eyelashes and or retouched.

Initial* I choose to waive the patch test and accept full responsibility for any reaction which might occur. (If patch test is requested, it must be done within 48 hrs before the scheduled appointment).

Initial* I understand that Lash lift & Dye has some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging or burning and blurry should the perming products enter into the eye.

Initial* I understand that if the Lash Lift & Dye products accidentally comes into contact with my eye, my eye will be flushed with water and medical attention may be required.

Initial* I understand that it is imperitive that I disclose all of the information requested on the disclosure & waiver form.

Initial* I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications.

Initial* I understand that additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure.

Initial* I agree that if I experience any ill effects with my lashes that I will contact the technician that performed this procedure.

Initial* I understand and consent to having my eyes closed and covered for the duration of the procedure.

Initial* I understand that I need to keep my eyelashes free of water for 48 hours after the Lash Lift &/or Dye.

Initial* I understand and agree to the after-care instructions provided by the technician. I realize and accept the consequences of failure to adhere to these instructions.

Photo/Video Consent

Pre & Post Care