Lash Lift & Tint Consent

Lash Lift & Tint Consent
Name

First NameLast Name
Address

Street Address

Street Address 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number

Area CodePhone Number
I am informing my technician of any of the following previous discomfort, stinging and adverse reactions:

Eye InfectionSkin DisorderInflammation of the skinEye DiseaseRecent Eye SurgeryBlephartitisWatery EyesHayfeverAllergiesBell's PalsyPrevious reactions to eye treatmentsContact LensesAllergies to latex/band aidsAllergies to adhesives, glues or bonding agentsAllergies to acetonePregnant or LacatingTaking HRT
Are you taking any medications?

YesNo
If yes, what medication are you taking?
Agreement: I request and consent to these procedures being carried out today without undergoing a sensitivity patch test. The sensitivity test, which if conducted may indicate my sensitivity/allergy to the products. I understand the contents of this form and take full responsiblity for my actions, thus absolving all other parties of their responsibilities, if any, associated with the supply of the products and services(s).
Date

MonthDayYear
Date
Signature

Clear
Parent/Legal Guardian Name (If under 18 years of age)
Name

First NameLast Name
Date

MonthDayYear
Date
Signature

Clear
Should be Empty: