Lash Lift/Brow Lam, Henna brows & Tinting
***Patch testing a minimum of 48hrs before you appointment is mandatory for these treatments, your appointment CAN NOT go ahead without one***. Please complete all details in full on the day of your arranged patch test.
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Date of booked patch test ( please call 07960566422 if not already arranged, appointment can not be booked without one), please do not complete this form if a date has not been booked
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Date
your patch test if for
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Lash Lift
Tint
Henna Brow
Bronsun Brow
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Name
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Date of birth
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Chose treatment
Please chose your treatment that you are having your patch test for
Please chose your treatment that needs to be patch tested
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Eyelash Lift/Brow Lam & tint (complete section 1&2)
Lash & Brow tinting (complete section 2)
Henna Brows & Brow Shaping/Waxing (complete section 3)
Are you pregnant?
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Yes
No
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1. Eyelash Lift/Brow Lamination
Please complete all details in this section if you are booking for a lash lift or brow lamination and section 2 for the tinting
12. Do you have any of the following eye disorders? Sty's, blepharitis, conjunctivitis, diabetic retinopathy, cysts in the eye area, cataract, dry eye, glaucoma, eyelid surgery or hay fever?
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By signing this agreement I am agreeing to have an eyelash lift and tint applied to my natural lashes and/or re-touched by my technician at Lash Perfection.
I Agree
I understand and agree to follow the aftercare instructions provided by my technician at the end of my first appointment for the care of my permed and tinted lashes. I realize an accept the consequences of failure to adhere to these instructions may cause the eyelashes to not stay permed as long as told.
I Agree
I understand that even though my technician perms the lashes using the proper technique, the instruments, tapes, cleaners, gel pads, adhesives and removers used may irritate my eyes or require a GP follow up.
I Agree
I understand there are risks associated with having and lash lift and tint. I further understand that as part of the procedure, eye irritation, pain, itching, discomfort and in rare cases eye infection or blurriness can occur. I agree that if I experience any of these that i will contact my technician asap and consult my GP at my own expense.
I Agree
I agree that in order to have the lash lift & tint I will need to keep my eyes closed and covered for the whole duration of the procedure. I also agree that I will need to be in a reclined position throughout it. Any medical conditions that may be aggravated by lying still for a prolonged period of time may mean I will not be able to have the procedure performed. I also understand and agree that the use of a mobile phone will be prohibited during the procedure
I Agree
I understand that Jayne Webb at Lash Perfection's liability is limited to the cost of the procedure performed. In the event of a dispute that can not be amicably resolved, Lash Perfection and the client agree to binding arbitration to resolve any disputes at the clients expense
I Agree
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2. Lash & Brow Tinting
Please complete all details in this section if you are booking in for tinting
Have you ever had a reaction to any hair colouring previously?
Yes
No
Have you ever had your lashes/brows tinted previously?
Yes
No
Are you currently using any over the counter or prescribed skin care products?
Yes
No
If answered yes, please list below
Do you have diabetes, lupus or any auto-immune disease?
Yes
No
If answered yes, please list below
Are you taking any medication?
Yes
No
If answered yes, please list below
Do you currently have any allergies?
Yes
No
If answered yes, please list below
I understand that tinting lashes has some inherent risk of irritation to the orbital eye area, including the eye itself. It could result in stinging or burning, blurry vision and potentially blindness should the tint enter the eye.
I Agree
I understand that if any of the tinting agent, developer or mixture of both accidentally comes into contact with my eye, my eye will be flushed with water and medical attention my be required.
I Agree
I understand that some irritation, itching or burning may occur to the skin when it comes into contact with the skin.
I Agree
I understand there may be some residual dark staining left on the skin following the tinting process of either my lashes or brows. This will fade within a short time.
I Agree
I understand that, while every attempt will be made to provide me with my chosen colour, everyone's hair absorbs colour differently and my final results my not be the colour i initially wanted
I Agree
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3. Henna Brows
Please complete all details in this section if you are booking for Henna Brows. This treatment will also include brow shaping/waxing
Brow henna is an organic naturally based product with over 99% of all ingredients coming from plants. No peroxide or ammonia are added. Brow henna contains henna plant and may contain some of the following essential oils: Cajaput, Cademom, Clove, Cypress, Eucalyptus, Lavender, Niaouli, Palma Rosa, Patchouli, Rose Geranium and tea tree. Henna may also include the following: Orange Juice, Lemon Juice, Sage, Wild Cherry Powder, Basil, Nutmeg, Cinnamon, Indigo, Cassia, Buxus Diocia, Amla, Olive Oil, Coconut Oil and Beet Powder. Brow Henna does NOT contain the black chemical P.P.D (para phenylene diamine).
To my knowledge I am not allergic to any of the above listed ingredients
I understand and acknowledge that I should avoid Henna if I have G6PD deficiency, have been advised to avoid Fava beans, Quinine, are extremely anemic, have serious citrus allergies or essential oil allergies
I Agree
I realize that my Henna Brow procedure is temporary and will potentially be staining my skin for 7-14 days and will start to fade as soon as 24 hour hours after the procedure is complete.
I Agree
I realize that my Henna Brow procedure will tint my brow hair for potentally up to 6 weeks.
I Agree
I understand that results will vary with each individual. Overall skin condition and aftercare will ultimately affect the retention of the Henna Brow results.
I Agree
I understand that Jayne Webb at Lash Perfection's liability is limited to the cost of the procedure performed. In the event of a dispute that can not be amicably resolved, Lash Perfection and the client agree to binding arbitration to resolve any disputes at the clients expense
I Agree
I agree to the patch test to ascertain potential allergic reactions to the Henna products. Pigments used have a low probability of allergic reactions but can not absolutely rule out the possibility of an allergic reaction.
I Agree
The risk of infection from the treatment is extremely minimal, the possibility of such an occurrence can not be totally precluded. Accordingly, I understand and accept this risk and release Lash Perfection from any liability related to the subject procedure, except instances of gross negligence.
I Agree
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Type a question
We hold your appointments just for you and ask that if you must cancel or reschedule any appointment please provide us with at least 24-hour notice. This way, we will be able to adjust our schedules accordingly and we may be able to accommodate other clients on our waiting list. We do, of course, understand that unavoidable issues come up and will do our best to work with you in case of an emergency. Last minute cancellations or ‘no shows’ will be charged a cancellation fee each time. Here is our general breakdown of cancellation fees: • Less than 24-hour notice will result in a charge equal to 50% of reserved appointment(s) • NO SHOWS’ will be charged 100% of service amount Please understand that it is your responsibility to remember your appointment dates and times in order to avoid missed appointments and cancellation fees. You are always welcome to call and double check any appointments if you’re unsure.
I agree to the above statement
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