LASH LIFT CONSENT FORM

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Appointment on

Date

I agree to have an eyelash lift applied to my natural eyelashes. By signing this agreement, I consent to the procedure of an eyelash perm by my technician. I understand there are risks associated with having an eyelash perm. I further understand that eye irritation, eye pain, eye itching, discomfort, and eye infection or blurriness could occur in rare cases as part of the procedure. I agree that if I experience any of these medical conditions with my lashes that I will contact my technician and consult a physician at my own expense. I understand that even though my technician perms the lashes using the proper technique, the instruments, tapes, cleaners, eye gel pads, adhesives, and removers used may irritate my eyes or require a physician's follow-up care. I understand and agree to the care instructions provided by my technician for the use and care of my permed eyelashes. I realize and accept the consequences of failure to adhere to these instructions may cause the eyelashes not to stay permed as long as told. I understand and consent to have my eyes closed and covered for the duration of the 60-minute procedure. I am informing my technician of the following conditions by marking them.

Current use of contact lenses which I agree to remove during the treatment.

YesNo

Current use of eyedrops of any kind, prescription or over the counter.

YesNo

Current allergies or sensitivities to instruments, fumes, tapes, cleaners, eye gel pads, adhesives, and removers that could cause my eyes to water and blink in excess.

YesNo

History of recurrent eye or tear duct infections.

YesNo

History of dry eyes or Sjogren's Syndrome

YesNo

Current allergies or sensitivities to instruments, fumes, tapes, cleaners, eye gel pads, adhesives, and removers that could cause my eyes to water and blink in excess

YesNo

Current allergies or sensitivities to instruments, fumes, tapes, cleaners, eye gel pads, adhesives, and removers that could cause my eyes to water and blink in excess

YesNo

Pregnant or breastfeeding

YesNo

Recent history of Chemotherapy

Other medical conditions which would prohibit or compromise the process and retention of this eyelash lift

I have received post care instructions and will follow them to ensure results of my procedure are satisfactory.*

Initial

Permission is granted to take photos of my eyes/face which may be used for marketing purposes on a website, salon, or class.*

Initial

I agree to the following eyelash perm post-op and maintenance instructions: No water can contact the eye area for 24 hours after the application. This agreement will remain in effect for this procedure and all future procedures conducted by my technician. I read English and understand that this consent agreement is legal and binding. I have read and fully understand all information in this agreement. I am over 18 years of age and consent to the agreement and treatment. I release my technician from all liability associated with this procedure, which is performed with the utmost attention to safety and proper application using tools and products that the technician has been professionally trained to use. There are no guarantees for the length of time the lashes will stay permed. I understand the aftercare instructions and will do my part to maintain my eyelashes. I understand that many factors may affect the life of the eyelash lift, such as water and moisture contact, weather conditions, and activities involving exposure to high temperatures. I verify that I have read and understood the above statements and agree to them by signing below.

Signature*

Date*

Date