Lash Lift & Tint Consent Form
The Browticians
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Previous discomfort, stinging and adverse reactions please check all that apply:
Skin disorders
Eye infections
Watery eyes
Bell's Palsy
Allergies to latex/band aids
Are you pregnant or lactating?
Inflammation of the skin
Recent eye surgery
Hayfever
Previous reactions to eye treatments
Allergies to adhesives, glues or bonding agents
Eye disease
Blepharitis
Allergies
Contact lenses
Allergies to acetone
Are you taking HRT?
Any medications?
Other relevant information:
Have you had eyelash or brow tinting, eyelash perming, eyelash extensions or semi permanent mascara applied previously?
*
Yes
No
If yes, which treatment?
Tinting
Eyelash perm/lift
Eyelash extensions
Semi permanent mascara
Did you experience any reaction to these treatments?
Yes
No
If yes, please detail:
If yes, did you seek medical advise from a doctor or specialist as a result of this reaction?
Yes
No
If yes, please detail:
Please read check and sign if you fully understand the following agreement:
*
I understand there are risks associated with having an eyelash lift & tint. I further understand that as part of the procedure, eye irritation, eye pain, eye itching, discomfort, and in rare cases eye infection or blurriness could occur. I understand that the instruments, tapes, cleaners, eye gel pads, adhesives, and removers used may irritate my eyes.
I agree that if I experience any of these medical conditions with my lashes that I will consult a physician at my own expense.
I understand there are no guarantees and RESULTS WILL VARY.
Because RESULTS VARY and are NOT GAURANTEED, refunds will not be issued if curl results are not desired. There will be a charge for re-do’s.
I understand that there are many factors that may affect the life of the lash lift and tint such as; water and moisture contact, weather conditions, and activities involving exposure to high temperatures.
Signature
*
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: