Yumi Lash Waiver Form

Name*

First NameLast Name

Todays Date*

MonthDayYear

E-mail*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Date of Birth*

MonthDayYear

Please select if you have any of the following

If you have any other eye disease or allergy not stated above please describe

Are you currently taking any medications?*

YESNO

Please list any medications you are currently taking

Are you pregnant or lactating?*

LASH LIFT WAIVER AND RELEASE FORM

I authorize Simply Relaxed to perform the Lash Lift procedure. I understand this procedure requires my lashes to be glued to a silicone pad with a water soluble adhesive and lifted onto a silicone pad with a fixing agent, a conditioning agent, Tint (optional) and nourishing oil. I understand that it is my responsibility to be still during the procedure and to keep my eyes closed during the process unless otherwise advised. I have been fully informed as to the methods and procedures concerning the Lash Lift procedure. The risks of the cosmetic procedure I have chosen have been disclosed to me. Although rare, some may result in complications such as transient eye redness and irritation and allergic reaction to the products used to lift the lashes and/ or the tape, anti- wrinkle gel patches or black eyelash tint. If at any time I (or the technician) are uncomfortable with the Lash Lift procedure, I will inform the technician and we will gladly rectify the problem, including ending the session if I (or the technician) wish. It has been represented to me that no guarantees, warranties, promises, commitments or other statements as to the results of this treatment have been made. I acknowledge that I have no particular representation or guarantees, and I am consenting to the procedure at my own risk. All conditions must be revealed or disclosed by me to the technician regarding my health history, medications being taken and any past reactions to products used or medications taken. Additional conditions could be discovered during the procedure, which could affect my ability to tolerate the procedure.

I herein signed, release, give up, acquit, and discharge Beautiful You and or
anyone affiliated there to including any partnership, corporations, or company associated with said individual from any claims or damages of any nature...

I have read Lash Lift waiver and release form and understand all the information provided to me.*

I AGREE

I, the client herein signed, for the purposes of documentation and results, hereby consent to “before and after”photographs, which may or may not be used for the purposes of advertising.*

Yes, I agree to before and after photo and acknowledge that photos can be used for documentation, results and advertising purposesYes, I agree to before and after pictures for documentation and results only but do NOT want them used for the purpose of advertisement.No, I do not want photos taken for any documentation, results or advertising.

Signature

Simply Relaxed lash lift consent form