LASH LIFT & TINT CONSENT FORM

Name *

First Name Last Name

Birth Date

Month Day Year

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Email *

example@example.com

Occupation: *

How did you hear about Karina’s Beauty Spa?

Website/online search Groupon Referral Facebook Instagram

If referral, please list name.

Have you had an Eyelash lift & tint in the past? *

Yes No

If yes, when?

Have you ever used hair color/ eyelash tint? *

Yes No

Have you ever had a allergic reaction to hair color/eyelash tint? *

Yes No

Do you wear contact lenses? *

Yes No

List any allergies you have:

I agree, Although every precaution will be taken to ensure your safety and well-being before, during, and after your eyelash lift, please be aware of the following information of possible risk.

I understand that there are risks associated with having an eyelash lift

I understand that as part of the eyelash lift procedure, eye irritation, eye pain, eye itching, discomfort, and in rare cases, eye infection or blurriness could occur.

I agree 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 that the instruments, tapes, cleansers, eye gel pads, adhesives, and/or removers may irritate my eyes or require physicians follow up care, even though my technician utilize correct techniques and follow proper safety protocols.

I understand an eyelash lift will lift my natural lashes. Depending on my natural lash lift length and strength, results may vary.

I understand and agree to care instructions provided by pack technician for the use in care of my eyelashes after the eyelash lift. I realized it a sept 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 the consent to having my eyes closed and cover for the entire duration of the procedure.

I understand I should come in makeup free to my appointment

I understand if any cancellations or rescheduling with less than 24 hours of notice or no-show appointments are subject to a cancellation fee amounting to 50% of the cost of the scheduled service.

I understand NO REFUNDS . All purchases are FINAL SALE .

I agree with the above *

Yes

I agree to the following eyelash lift care and maintenance instructions no water can come in contact with the eye area for 48 hours after the applications.

This agreement will remain in effect for this procedure in all future procedures conducted by my technician.

I have read the above information. If I have any concerns, I will address this with my aesthetician/technician. I give permission to my aesthetician/technician to perform the eyelash lifting procedure we have discussed and will hold her and her staff harmless from any liability that may result from this treatment. I have accurately answer the questions above, including all known allergies, prescription drugs, or products I am currently ingesting or using topically. I understand my aesthetician/technician will take every precaution to minimize or illuminate negative reactions as much as possible. In the event I may have additional concerns questions or concerns regarding my treatment, I will consult the aesthetician/technician 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 they have sufficient opportunity for discussion to have any questions answered. I understand the procedure and acccept the risk. I do not hold the aesthetician/technician, who signature appears below, responsible for any of my conditions that were present, but not disclose at the time of this procedure that may be affected by the treatment performed today. By signing below, I verify that I have read and understand the above statements and agree to them.

Signature *

Clear

Date *

Date