LASH LIFT

LASH LIFT

CONSENT FORM
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MEDICAL/HISTORY DATA
Do you have any of the following conditions?

PsoriasisDiabetesEczemaEye SensitivityAllergies to adhesive tapesDry eyesOther
Are you currently taking any medications? If yes, please list them below:
Please list any eye drops or eye medications you are using
Do you wear contacts?

YESNO
AUTHORIZATION

I give permission to Sophia Cooper to perform the eyelash extension procedure we have discussed and will hold her harmless from any liability that may result from this treatment. I understand waxing does have certain side effects and risks such as redness, swelling, itchiness, etc. If I have any concerns I will address those with my aesthetician. I understand my aesthetician will take every precaution to minimize or eliminate negative reaction as much as possible.
I have read and understand the contents of each paragraph above. I acknowledge this is a contract and that I have received no warranties or guarantees with respect to the benefits to be realized from, or consequences of, the aforementioned procedure(s). I further acknowledge that at the time of signing this consent to this procedure(s), I was of sound mind and capable of making independent decisions for myself.
Are you able to keep your eyes closed for 60 Min?

YESNO
Signature of the Patient*

Clear
Date*

MonthDayYear
Date
Should be Empty:

LASH LIFT

MEDICAL/HISTORY DATA

AUTHORIZATION