Lash Extensions/Lash Lifting & Tinting/Brow Lamination Consent Form

Lash Extensions/Lash Lifting & Tinting/Brow Lamination Consent Form
PLEASE COMPLETE ENTIRE FORM
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Emergency Contact Name

First NameLast Name
Phone Number

Area CodePhone Number
Please list ANY allergies you have (including cosmetics/ingredients):
Are you wearing contact lenses? *If yes, contacts MUST be removed to perform lash lifting and eyelash tinting. Contacts may be worn during lash extension application or brow lamination.

Yes, I wear contact lensesNo, I do not wear contact lensesI wear glasses. *If you wear glasses and are getting lash extensions, please let your lash tech look at your lashes with your glasses on, so we can choose the correct lengths of extensions so they are not hitting your glasses!
Eyelash Extensions:
Are you allergic to Acrylate/Cyanocarylate (bonding agent)? *If you are allergic, we are unable to apply eyelash extensions today.

YesNoDon’t know
Have you ever had a reaction to adhesive tape, skin safe glue, topical creams, nail adhesives, or other topical products?

YesNo
If yes, please explain:
Do you have any eye disease, condition or injury that has affected your lash growth?

YesNo
If yes, please explain:
Do you have any of these conditions today?

Alopecia (may affect lash extension retention)AsthmaBack pain or Back injury (this may make it difficult to lay down for a long period of time)Bell’s PalsyBlepharitis (may cause build up of eye boogers/crust around lash extensions)ClaustrophobiaCold SoresConjunctivitis/ Pink Eye (we will not perform any service with conjunctivitis present)DiabetesDry EyesEye Sties or Sores (we will not perform any service with conjunctivitis present)Herpes of the Eye(we will not perform any service with herpes present)Intense StressExcessive watering of the eye (may affect lash extensions and lash lifting/tinting)Light SensitivityMigrainesOcular RosaceaRosaceaSensitive EyesStroke/TIAThyroid Disease (may affect lash extension retention)Trichotillomania (may affect lash extension retention)Recent Eye Injury (we will not perform any service with eye injury present)Current Eye Irritation (we will not perform any service with eye irritation present)
Please list any other health condition not listed:
Are you pregnant or nursing?

YesNo
Do you wear contacts or glasses?

ContactsGlassesBothNeither
Do you use prescription or over-the-counter eye drops? *If so, your lash extension retention may be affected.

YesNo
Have you ever had lash extensions?

YesNo
Have you ever had lash extensions professionally removed?

YesNo
Have you ever used waterproof mascara, eyeliner or eyeshadow? *If so, stop use immediately. Waterproof eye makeup is prohibited while wearing lash extensions. Waterproof makeup is safe for lash lifting, tinting and brow laminations after 24 hours.

YesNo
Do you go tanning?

In salonOutdoorSpray tanNone of the above
Have you had any recent facial treatments, laser treatments, Botox/Filler or permanent makeup services that would cause your face to be sensitive to the touch today?

YesNo
Have you had any recent Botox, Juvederm or other injectables?

YesNo
Are you currently using Latisse or another lash serum? *Most lash serums are safe to use while wearing lash extensions. Please ask your lash technician if the brand you are using is lash extension safe! If the serum is not safe, your lash extension retention may be affected.

YesNo
What side do you most often sleep on? *Please be aware, side sleeping and stomach sleeping will affect lash extension retention. We suggest sleeping on your back only to maximize lash retention.

LeftRightBackStomach
How fast do you feel your hair grows?

FastSlowNormal rate
Signature

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Date

MonthDayYear
Date
Lash Lifting and Lash Tinting:
Have you ever had a lash lift?

YesNo
If YES, when? *Lash lifts should be done at least 6 weeks apart to prevent over-processing.
Have you ever used eyelash tint?

YesNo
Have you ever had an allergic reaction to eyelash tint? If YES, we will not perform the tinting portion of the lash lifting process.

YesNo
If you had an adverse reaction to Lash Lifting or Lash Tinting in the past, please explain:
Do you wear contact lenses?

YesNo
Are you currently using eye drops of any kind, prescription or over the counter?

YesNo
Do you have a history of recurrent eye or tear duct infection?

YesNo
Do you have a history of dry eyes or Sjorgen's Syndrom?

YesNo
List any allergies you have:
List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process and retention of this lash lift:
Signature

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Date

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Brow Lamination and Brow Tinting:
Have you ever had a brow lamination?

YesNo
If YES, when? *Brow laminations should be done at least 8 weeks apart to prevent over-processing.
Have you ever used eyebrow tint before?

YesNo
Have you ever had an allergic reaction to eyebrow tint before? If YES, we will not perform the brow tinting portion of the brow lamination.

YesNo
Have you ever had your brows tinted?

YesNo
If you had an adverse reaction to Brow Laminations or Brow Tinting in the past, please explain:
If you would like your eyebrows WAXED during your Brow Lamination service you understand you cannot be on any of the following medications or topicals: Accutane, prescription strength retinol/tretinoin, any prescription strength acne topicals, Differin, face washes containing Benzoyl Peroxide, Salicylic Acid, Glycolic Acid, other AHAs OR recent facial treatments that exfoliated the skin.

I understand
Do you wear contacts?

YesNo
I consent to "before and after" photos to be used on Bliss Studio's social media sites.

YesNo
Please read the following risks associated with each service:
Although every percaution will be made to ensure your safety and well-being before, during and after your service, please be aware of the possible risks below:
Lash Extension Risks:
I understand a FULL SET of lash extensions takes anywhere from 1.5 hours to 2.5 hours to complete. I have used the restroom and silenced my phone so I do not disturb the lashing process.

I understand
I understand coming to my appointment with ANY makeup on (mascara, eyeliner, foundation, eyeshadow) can affect my retention. My lash technician will cleanse my lashes with lash shampoo to remove the makeup to the best of their ability, but I do understand by coming to my appointment with makeup on has caused us to spend less time lashing and my retention may be affected.

I understand
I understand while every attempt will be made to give me the lash length and fullness of my choosing, if my natural lashes are too sparse, short or unhealthy my results may not be exactly what I envisioned.

I understand
I understand lash extensions are applied to my natural lashes and not applied to my eyelids. I understand I will naturally shed 3-5 extensions a day.

I understand
I understand in order to keep my lash extensions looking full, I need to book fills every 2 or 3 weeks.

I understand
I understand that lash extension services have some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging and burning, blurry vision and potential blindness should the adhesive enter the eye or should an allergic reaction occur.

I understand
I understand there is a risk of irritation, burning or itching if the adhesive comes in contact with my skin.

I understand
I understand if there is an allergic reaction I will contact Bliss Studio & Spa LLC immediately to have my extensions removed free of charge.

I understand
I understand if I have an allergic reaction to lash extensions, lash tinting, lash lifting OR brow lamination I will NOT receive a refund for the service performed.

I understand
I understand I must keep my eyes closed for the entire duration of the lash extension service. If I open my eyes I may experience burning, itchiness or blury vision from the adhesive fumes.

I understand
I understand if the adhesive comes into contact with my eye, my lash technician will flush my eyes with water immediately and we will stop the service. If I choose to seek medical attention it will be at my own expense.

I understand
I understand additional conditions could occur or be discovered during the procedure that could affect my ability to tolerate the procedure. I will still pay for my service, in full, even if I choose not to complete the service.

I understand
I understand if is imperative that I disclose all of the information requested in this health history form.

I understand
I understand the following aftercare instructions for lash extensions: DO NOT get extensions wet or expose them to steam for 24 hours. DO NOT use products containing oils around your orbital area, ever. DO NOT get spray tans without wearing goggles over lash extensions. DO NOT sleep on your stomach or side. DO NOT touch, pull or play with extensions using your fingers. (Use provided mascara wand to brush them) ALWAYS wash off eye makeup daily to avoid build up and irritation. (Lash shampoo is available for purchase)

I understand
Lash Lifting & Lash Tinting Risks:
I understand that as part of the eyelash lifting procedure, eye irritation, eye pain, eye itching, discomfort, and in rare cases, eye infection or blurriness could occur.

I understand
I undertand that if I experience any of these conditions with my eyelashes or eyes, that I will contact my technician; if I choose to consult a physician, it will be at my own expense.

I understand
_____I understand that if 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 may be required at my own expense.

I understand
I understand that the instruments, tapes, cleaners, eye gel pads, adhesives, tint, and/or removers may irritate my eyes or require a physician’s follow-up care, even though my technician utilized correct techniques and followed proper safety protocols.

I understand
I understand that an eyelash lift will lift my natural eyelashes. Depending on my natural eyelash length and strength, results may vary. in some cases lashes may not lift at all.

I understand
I understand there is a small risk my lashes could be over processed. If lashes are over processed they may become brittle and break easily. I understand my lashes will go back to normal once I have shed the over processed lashes and new lashes have grown in their place.

I understand
I understand and agree to the aftercare instructions provided by my technician for the use and care of my eyelashes after the eyelash lift. I realize and accept that the consequences of failure to adhere to these instructions may cause the eyelashes to not stay as lifted as long as originally told.

I understand
I agree to the following eyelash lift care and maintenance instructions: DO NOT let water come in contact with the eye area for 24 hours after the application. DO NOT use a lash curler for 24 hours.

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

I understand
I understand lash lifts last approximately 6-8 weeks and lash tinting lasts approximately 3-4 weeks

I understand
Brow Lamination & Brow Tinting Risks:
I understand that as part of the brow lamination and brow tinting procedure, eye irritation, itching, discomfort, or allergic reaction can occur.

I understand
I understand there is a small risk my eyebrows could be over processed during the lamination portion of the service. I understand if this happens the brow hairs will become brittle and break easily. I understand my brows will go back to normal after I have shed the over processed brows and new brow hairs have grown in their place.

I understand
I understand that some irritation, itching or burning may occur to the skin which comes in contact with the tinting agent.

I understand
I understand that there may be some residual dark staining left on the skin following the tinting process of either my lashes, brows or both. This will fade and go away within a short time.

I understand
I understand that, while every attempt will be made to provide me with my chosen color, everyone’s eyebrow hair absorbs color differently and my final results may not be the color I initially wanted.

I understand
I understand that over the course of several weeks, the tint will gradually lighten and fade. Re-tinting will be required to keep the new color fresh. Most clients need to re-tint every 3-4 weeks. And a new Brow Lamination every 8 weeks.

I understand
Type a question
I have read the above information. If I have any concerns, I will address these with my esthetician. I give permission to my esthetician to perform the procedure we have discussed, and will hold him/her and his/her staff harmless from any liability that may result from this treatment. 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 esthetician 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 treatment, I will consult the esthetician 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 esthetician, or Bliss Studio & Spa LLC, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.
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Lash Extensions/Lash Lifting & Tinting/Brow Lamination Consent Form

PLEASE COMPLETE ENTIRE FORM

Eyelash Extensions:

Lash Lifting and Lash Tinting:

Brow Lamination and Brow Tinting:

Please read the following risks associated with each service:

Lash Extension Risks:

Lash Lifting & Lash Tinting Risks:

Brow Lamination & Brow Tinting Risks: