Korean Lash Lift & Tint Intake Form
General Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Phone#
*
Format: (000) 000-0000.
Email
*
example@example.com
Occupation
Emergency Contact Name
Phone#
Format: (000) 000-0000.
How did you hear about us?
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Lash Lift & Tint Screening
Have you ever had an allergic or adverse reaction to a lash lift/perm, lash tint, hair dye, brow tint, lash adhesive, or other eye-area cosmetic product?
Yes
No
Do you have any known allergies or sensitivities to tint, hair dye, peroxide/developer, perming solutions, adhesives, latex, or cosmetic ingredients?
Yes
No
Do you currently have redness, swelling, itching, irritation, excessive watering, discharge, or pain in or around either eye?
Yes
No
Do you currently have, or have you recently had, pink eye/conjunctivitis, a stye, blepharitis, or another eye infection?
Yes
No
Do you currently have broken or irritated skin, cuts, dermatitis, eczema, psoriasis, or another skin condition around the eyes?
Yes
No
Have you recently had eye surgery, LASIK, permanent eyeliner, cosmetic tattooing, or another procedure around the eye area? If yes, when?
Yes
No
Do you have extremely sensitive or excessively watery eyes?
Yes
No
Do you wear contact lenses? (Contacts must be removed before your service.)
Yes
No
Have you had a lash lift or lash perm within the last 6–8 weeks?
Yes
No
Are your natural lashes currently damaged, brittle, breaking, unusually dry, or shedding excessively?
Yes
No
Are you currently using a prescription lash-growth product or lash serum?
Yes
No
Have you previously experienced lash breakage or overprocessing following a lash lift?
Yes
No
Have you received a patch test with the products being used today?
Yes
No
Is there anything else regarding your eyes, lashes, skin, allergies, medications, or recent treatments that your esthetician should know before performing your Lash Lift & Tint?
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Lash Lift & Tint Consent Form
I acknowledge:
*
I understand that a Lash Lift & Tint involves the use of chemical lifting and tinting products on my natural eyelashes and in close proximity to my eyes.
I understand possible reactions include redness, irritation, itching, watering, swelling, sensitivity, or an allergic reaction.
I understand that an allergy or sensitivity may develop even if I have previously received this service or used similar products without a reaction.
I understand that a patch test may reduce risk but cannot guarantee that a reaction will not occur.
I understand that chemical processing can potentially cause dryness, brittleness, frizzing, breakage, or damage to my natural lashes, particularly if the lashes are already compromised or overprocessed.
I understand that results depend upon my natural lash length, condition, growth pattern, growth cycle, and previous treatments.
I understand that the exact curl, lift, darkness, appearance, and longevity cannot be guaranteed.
I understand that my esthetician may modify, discontinue, postpone, or refuse the service if my eyes, skin, or natural lashes appear unsuitable for treatment.
I agree to immediately tell my esthetician if I experience burning, stinging, itching, pain, or significant discomfortduring the service.
I confirm that I have disclosed relevant allergies, sensitivities, medications, eye conditions, previous reactions, and recent treatments.
I agree to follow the recommended Lash Lift & Tint aftercare instructions.
I have had the opportunity to ask questions and voluntarily consent to receiving a Lash Lift & Tint.
By signing below, I acknowledge there is a no-refund policy in place. By paying for my service at the completion, I am acknowledging that I am satisfied with my services provided and credit card disputes will then be considered frivolous.
I hereby grant and authorize Lancaster’s Luxe Lashes the right to take, edit, alter, copy, exhibit. publish, distribute and make use of any and all pictures. video, and/or audio is taken of me to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social networking sites, and other print or digital communications without payment or any other consideration. This authorization extends to all languages, media, formats, and markets now known or later discovered. I waive the right to inspect or approve the finished product wherein my likeness appears, including a written or electronic copy. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I hereby hold harmless and release Lancaster’s Luxe Lashes from all liability, petitions. and causes of action which I. my heirs. representatives. executors. or any other persons may make while acting on my behalf or on behalf of my estate.
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Consents
Take Photo
*
Name Printed
*
Signature
*
Submit
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