LASH LIFT AND TINT FORM
Name
First Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Todays date
-
Month
-
Day
Year
Date
Do you wear contacts?
Yes
No
Do you have any allergies?
Yes
No
Have you had a lash lift and tint before?
Yes
No
Are you pregnant?
Yes
No
Any eye problems in the last 4 weeks?
Yes
No
Do you have asthma?
Any of the following?
Alopecia
Eczema
Conjunctivitis
Sensitive eyes
Psoriasis around eye
Recent eye infection
Trichotillomania
Allergy to plasters
Allergic to latex
Diabetic retinopathy
Dry eye syndrome
Cataracts
Other
How did you hear about us?
Instagram
Facebook
Friend
Other
Have you had tinting before?
Do you have any known allergies?
I allow Yem at Beauty by Yem to take a before / after picture of my service - these photos may be used on our website, our Instagram or Facebook page etc.
Initial
I confirm (to the best of my knowledge) that the information I have provided is accurate and complete. I have not withheld any information that may be relevant to my treatment and/or the result thereof. I am aware that there are often inherent risks associated with skin care services including tinting procedures, and that the service I am about to receive could have unfavorable results including, but not limited to: irritation, burning, redness, dye on the skin etc.
Initial
By signing below, I further agree that I will not hold Beauty By Yem or its affiliates responsible should there be any unfavorable outcome or result.
Initial
I release my technician/Beauty by Yem from all liability associated with this procedure. Our company is not responsible for any technicians errors. I understand that I have been advised to follow the aftercare protocol from my technician after the service.
Initial
Name
First Name
Last Name
Signature
Date
-
Month
-
Day
Year
Date
Technician Signature
Date
-
Month
-
Day
Year
Date
Submit
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