LASHES & BROWS INFORMATION AND CONSENT

Full Name:*

DOB:

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number:*

E-mail Address:*

example@example.com

READ SELECTIONS BELOW CAREFULLY. (SELECT ALL THAT APPLY TODAY AND FOR ANY SERVICES THAT YOU MAY WANT IN THE FUTURE*

I understand that the treatment is a safe procedure and there is no recovery time for most people.*

Please initial

I understand that tinting eyelashes or eyebrows, lifting eyelashes, and brow lamination has some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging or burning, blurry vision, and potential blindness should the solution enter the eye for an extended period of time.*

Please initial

I understand that if the tinting/lamination agent, developer, or mixture of both accidentally comes into contact with my eyes, my eyes will be flushed with water and saline solution and medical attention may be required.*

Please initial

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

Please initial

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.*

Please initial

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

Please initial

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 retint every 3-4 weeks.*

Please initial

How did you hear about us?*

Have you ever had your lashes and/or brows tinted or laminated?*

YesNo

If Yes, When?

Have you ever had a lash lift/lash curl?*

YesNo

If Yes, When?

Were you happy with the results?

Have you ever had an adverse reaction to hair color or previous tinting procedures? Or any reaction to the lash perm or neutralizer for lash lift/lash curl/brow lamination? *

Do you wear contacts?*

YES (CONTACTS MUST BE REMOVED FOR LASH LIFT TREATMENT)NO

Have you undergone any recent eye surgery?*

YESNO

If Yes, When?

TREATMENT WILL BE POSTPONED IF ANY EYE SURGERY HAS BEEN PERFORMED IN THE LAST 6 MONTHS

Do you have any eye condition or injury?*

YesNo

Are you allergic to latex or rubber?*

YesNo

Please list any medications you are currently taking:*

Do you have any intolerance/ allergy to: chemicals, fragrances, odors, hair dyes, color ingredients?*

YesNo

PLEASE CHECK ALL THAT APPLY*

	YES	NO
STRESS
LASIK EYE SURGERY
PERMANENT EYE MAKEUP
DIABETES
BLEPHAROPLASTY
SEASONAL ALLERGIES
ALOPECIA
PINK EYE
HORMONAL IMBALANCE
HYPERSENSITIVE EYES
THYROID DISEASE
LUMP/CYSTS
COLD SORES AROUND EYES
PSORIASIS
STY OF THE EYE

Photographs: I give permission for photographs to be used by Viso Bello Spa for educational plus promotional purposes. Complete patient confidentiality will be maintained at all times.

PLEASE INITIAL

A Patch test is recommended for all first time clients, please call me directly at 203.437.2121 to discuss and schedule this quick process prior to your appointment. Alternatively you may waive the patch test requirement by signing here*

Name*

First NameLast Name

Signature*

Date*

Date

Please read, sign, and return:

CANCELLATION POLICY

Your spa treatments are reserved especially for you. We value your business and ask that you respect the spa's scheduling policies. Should you need to cancel or reschedule, Please notify us at least 24 hours in advance. Any cancellations with less than 24 hours notice are subject to a cancellation fee amounting to 50% of the cost of the scheduled service.

Clients who miss their appointments or arrive 15 minutes or more late to their appointment without giving any prior notice will be charged in full to the credit card on file for the scheduled service. We recognize the time of our clients and staff is valuable and have implemented this policy for this reason. When you schedule your appointment with us you are agreeing to these policies.

At Viso Bello Spa we understand that life can sometimes prohibit our clients from attending a scheduled appointment. However, due to our high volume of appointment requests, we ask that clients who find themselves repeatedly needing to reschedule consider contacting us for same day availability. We sincerely appreciate your understanding.

SPA ETIQUETTE

We strive to maintain a relaxing and professional atmosphere at all times. With this goal in mind please review the following:

Children: To ensure the safety of your children, and the serene environment for our clients, please make other arrangements for your children during your appointment. Children are not permitted in the lobby or treatment areas unless they are receiving a service. If you arrive to your appointment with children, you will be asked to reschedule and you will be charged for a missed appointment.

Cell Phones/ Devices: Please turn off your cell phone upon entering the lobby so as not to disturb other guests. If you must take a call, please do so outside.

Pets: No pets are allowed in our lobby or treatment rooms unless they are designated service animals.

Inappropriate Behavior: We reserve the right to refuse or terminate any appointment for inappropriate behavior. If an appointment is terminated due to lewd or otherwise offensive behavior, the full amount of the scheduled service will be charged. If an appointment is terminated for these reasons we reserve the right to refuse future appointments as well.

RETURN POLICY

All sales are final, no returns or exchanges.

Signature*