Lash Lift + Brow Lamination + Tint
Consent Form
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Referred by:
Client health history
Please list all current medications you are taking (including over-the-counter herbs, vitamins and supplements)
I am informing my technician of any of the following contraindicated conditions for the lash lift.
*
Allergies to adhesive tape, fumes or eye remover
Dry Eye Syndrome
Sjorgen's Syndrome
Currently having Chemotherapy
Ocular Rosacea
None of the above
Please list any allergies you have (including cosmetics/ingredients):
I am informing my technician of any of the following contraindicated conditions for the brow lamination.
*
Currently having Chemotherapy
Psoriasis
Eczema
Alopecia
Sun Burn
Ultra Sensitive Skin
Wounds in the treatment area
None of the above
I consent to having my eyes closed and covered for the duration of the 45-90 minute procedure.
*
Yes
No
I wear contacts
*
Yes
No
Is there anything else we should know?
Please provide picture of treatment area:
Browse Files
Cancel
of
Informed consent
Although every precaution will be taken to ensure your safety and well-being before, during and after your brow Lamination/ Lash Lift/ Tint, please be aware of the following information and possible risks. Please initial to confirm:
I agree to have an eyelash lift, brow lamination and/or eyelash tint applied to my natural eyelashes and/or retouched.
*
Initial
I understand there are risks associated with having an eyelash perm, brow lamination and/or eyelash tint.
*
Initial
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.
*
Initial
I understand that some mild but normal symptoms may occur with the brow lamiation depending on the sensitivity of my skin during the procedure and will subside in 24 hours. These symptoms may include: mild tingling, slight redness due to brushing the hairs, slight warmth in the area. 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.
*
Initial
I understand that even though my technician perms the lashes/brows using the proper technique, the instruments, tapes, cleaners, eye gel pads, adhesives, and removers used may irritate my eyes/brows or require a physician’s follow-up care.
*
Initial
I understand and agree to the care instructions provided by my technician for the use and care of my permed and/or tinted eyelashes/eyebrows. I realise and accept the consequences of failure to adhere to these instructions may cause the eyelashes to not stay permed as long as told.
*
Initial
I agree to the following Post- Lash Lift:No water can come in contact with the eye area for 24 hours after the application.Avoid makeup such as mascara, eyeliner or brow pencil for the first 24 hours.Avoid using oil containing sunscreens, moisturizers and cleansers on lashes for the first 24 hours.
*
Initial
I understand this agreement will remain in effect for this procedure and all future procedures conducted by my technician.
*
Initial
I understand that it is imperative that I disclose all of the information requested in the client profile/health history.
*
Initial
I have cited all conditions and circumstanced regarding my health history, medications being taken, and any past reactions to products or medications.
*
Initial
I am over 18 years of age and consent to the agreement and to treatment or have a parent with me that consents to this service.
*
Initial
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.
*
Initial
There are no guarantees for length of time the lashes will stay permed.
*
Initial
I understand that there are many factors that may affect the life of the eyelash lift such as water and moisture contact, weather conditions, and activities involving exposure to high temperatures.
*
Initial
By signing this agreement, I consent to the procedure of an eyelash perm, brow lamination or eyelash tint by my technician.
*
Initial
I agree this constitutes full disclosure, and that is supersedes any previous verbal or written disclosures.
*
Initial
I read English and understand that this consent agreement is legal and binding.
*
Initial
I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered.
*
Initial
By signing below, I verify that I have read and understand the fabove statements and agree to them.
*
Initial
Date
*
/
Day
/
Month
Year
Date
Signature
Submit
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