Lash Lift Tint Consent Form

LASH LIFT & BROW LAMINATION CONSENT FORM
Name:*
Phone*
Date of birth*

MonthDayYear
Date
Address
Email*
example@example.com
How did you hear of us?
Are you over 18 ? *

YesNo
If no, state age -- Parental consent will be required.
Do you use lash/brow growth products?*

YesNo
Do you go*

Sun Bed TanningSpray TanNone
Do you wear...*

GlassesContactsBothNone
Are you pregnant? *

YesNoI Dont Know
If yes, do you have permission to get a lash lift / brow lamination?

YesNo
Do you have any eye diseases?*

YesNo
If yes, please list the disease/s
Any conditions that have affected your hair/lash growth or loss?*

YesNo
If yes, please list the condition/s
Allergies to Acrylate/Cyanoacrylate/Perming Lotion (bonding agent)?*

YesNo
Any reactions to adhesive tape, topical creams, other topical products?*

YesNo
If yes, list reaction/s
do you have any allergies?*

YesNo
If yes, list allergies
Is there anything else we should know about?
Check any of the following conditions that apply

AlopeciaConjunctivitisLight/ Eye sensitivityAsthmaDiabetesMigrainesBack painDry eyesRecent eye surgeryBlepharitisCurrent eye irritationCancer/ChemoHormonal ImbalanceWatery eyesClaustrophobiaIntense stress
Is there anything else we should know about?
Please Read, Understand & Sign The Following:

Although every precaution will be taken to ensure your safety and wellbeing before, during and after your lash lift and brow lamination + tint application, please be aware of the following information and possible risks.
I understand that lash lift / brow lamination + tint services have some risk of irritation to the orbital eye area (including the eye itself and skin), could result in stinging, burning, blurriness and itching may occur if the bonding/perming agent comes into contact with it. If the bonding/perming agent comes into contact with the eye, it will be flushed with water, and I will be assisted in seeking medical attention immediately.*

Yes, I understandNo, I don't understand
I understand that this is a semi permanent procedure, as my natural lashes will continue to grow and fall normally, making touchup or "fill" appointments necessary to maintain the original look achieved by perming lashes that have grown out. Most clients require a fill appointment every 6-8 weeks.*

Yes, I understandNo, I don't understand
I have cited all conditions & circumstances regarding my health history, medications taken, & any past reactions to products or medications.*

Yes, I have cited all conditionsNo, I have not cited all conditions
I understand that additional conditions could occur or be discovered during the procedure which could my ability to tolerate the procedure.*

Yes, I understandNo, I don't understand
“before and after” pictures for the purpose of documentation, potential advertising and promotional purposes without payment or any other form of compensation. I understand that my image may be edited, copied, exhibited, published or distributed. Photos, video and audio may be used for the following purposes:
~ Website advertising ~ Marketing purposes ~ Take home manuals ~ Social media platforms ~ Informational presentations ~ Educational purposes
I will be consulted about the use of the photographs or video recordings for any other purpose other than those listed above.
I consent to “before and after” pictures AND OR videos for the purpose of documentation, educational, and advertising and promotional purposes.*

Yes, I consentNo, I don't consent
I understand that if I have any concerns, I will address them with my technician. I give permission for my technician to perform a lash lift / brow lamination + tint procedure and will hold Tu Lumia harmless & nameless from any liability that may result from this session. I have accurately answered the questions above, including all known allergies, prescription drugs, or products I am currently ingesting or using topically. I understand my technician will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my service, I will consult my technician immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the technician responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today.*

Yes, I have read and understand all of the followingNo, I have read and don't understand all of the following
Client Signature:*

Clear
Client Printed Name:*
Date*

MonthDayYear
Date
If under the age of 18 years, you must have a parent or guardian's consent before getting a lash lift & tint.
Parent/Guardian Signature:

Clear
Parent/Guardian Printed Name:
Date

MonthDayYear
Date
Should be Empty:

LASH LIFT & BROW LAMINATION CONSENT FORM

Please Read, Understand & Sign The Following: