Lash Lift & Tint Consent

Name

First NameLast Name

Email

example@example.com

Phone Number

Format: (000) 000-0000.

I am informing my technician of any of the following contraindicated conditions.

Have you had an eyelash lift in the past?

Have you ever used hair color/eyelash tint?

If answered no to the question above, SKIP this question. If answered yes, have you ever had an allergic reaction to hair color/eyelash tint?

Do you wear contacts?

Do you have any allergies?

Do you have a history of recurrent eye or tear duct infections?

I am currently using eye drops, prescription, or any over the counter medications

If answered no to the question above, SKIP this question. If answered yes, list what brand of eye drops, any prescriptions or over the counter medications below:

List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process and retention of this eyelash lift. If you have none, please select "none"

I consent to having my eyes closed and covered for the duration of the 45 minute procedure.

initial

Although every precaution will be taken to ensure your safety and well-being before, during, and after your eyelash lift, please be aware of the following information and possible risks. Please initial:
__ I understand that there are risks associated with having an eyelash lift.
__ I understand that as part of the eyelash lift procedure, eye irritation, eye pain, eye itching, discomfort, and in rare cases, eye infection or blurriness could occur.

__ I agree that if I experience any of these conditions with my eyelashes or eyes, that I will contact my technician; if I choose to consult a physician, it will be at my own expense.
__ I understand that the instruments, tapes, cleaners, eye gel pads, adhesives, and/or removers may irritate my eyes or require a physician’s follow-up care, even though my technician utilized correct techniques and followed proper safety protocols.
__ I understand that an eyelash lift will lift my natural eyelashes. Depending on my natural eyelash length and strength, results may vary.
__ I understand and agree to the care instructions provided by my technician for the use and care of my eyelashes after the eyelash lift. I realize and accept that the consequences of failure to adhere to these instructions may cause the eyelashes to not stay as lifted as long as originally told.
__ I understand and consent to having my eyes closed and covered for the entire duration of the procedure.

initial

I agree to have an eyelash lift (perm) and/or eyelash tint applied to my natural eyelashes and/or retouched. By signing this agreement, I consent to the procedure of an eyelash perm or eyelash tint by my technician. I understand there are risks associated with having an eyelash perm and/or eyelash 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 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 and/or tinted eyelashes. I realize and accept the consequences of failure to adhere to these instructions may cause the eyelashes to not stay permed as long as told. 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 using oil containing sunscreens, moisturizers and cleansers of on lashes Acknowledgement and Waiver 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. 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 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 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 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. By signing below, I verify that I have read and understand the above statements and agree to them.

Signature

Date