Lash Lift Intake

  • Client Questionnaire

  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Okay To E-Mail?
  • Okay to Call?
  • Okay to Text?
  • Format: (000) 000-0000.
  • Do we have permission to show your non-identifying photos for social media purposes?
  • How did you hear about Estie Co.?

  • Medical History & Intake

  • Have you had an eyelash lift in the past?
  • Have you had an eyelash tint in the past?
  • Have you ever used hair color/eyelash tint?
  • Have you ever had an allergic reaction to hair color/eyelash tint?
  • Do you normally spray tan?
  • Do you use or have you used Retin-A or Accutane?
  • Are you pregnant or on any fertility drugs?
  • Do you wear contact lenses?
  • Have you received Botox, Juvederm, or other dermal fillers in the last two weeks?
  • Do you have a history of recurrent eye or tear duct infections?
  • Do you have a history of dry eyes or Sjogren's Syndrome?
  • Do you have a recent history of chemotherapy?
  • Do you have a current use of eye drops of any kinds, prescription or over-the-counter?
  • Have you ever experienced an allergic reaction to any of the following?

  • I have read and completed this questionnaire truthfully. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin and eyes from treatments received. The treatments I receive are voluntary and I release the company (Estie Co. LLC)  and/or lash artist from liability.

  • Date
     / /

  • Informed Consent

  • Although every precaution will be taken to ensure your safety and wellbeing 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, 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 have my eyes closed and covered for the entire duration of the procedure.
       I understand that tinting lashes or brows has some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging or burning, blurry vision and potentially blindness should the tint enter into the eye.
       I understand that if the tinting agent, developer, or mixture of both accidentally comes into contact with my eye, my eye will be flushed with water and medical attention may be required.
       I understand that some irritation, itching or burning may occur to the skin which comes in contact with the tinting agent.
       I understand that there may be some residual dark staining left on the skin following the tinting process of either my lashes, brows or both. This will fade and go away within a short time.
       I understand that, while every attempt will be made to provide me with my chosen color, everyone’s hair absorbs color differently and my final results may not be the color I initially wanted.
       I understand that over the course of several weeks, the tint will gradually lighten and fade. Re-tinting will be required to keep the new color fresh. Most clients need to re-tint every 3-4 weeks.

  • I agree to the following eyelash lift care and maintenance instructions:

  • This agreement will remain in effect for this procedure and all future procedures conducted by my technician. I have read the above information. If I have any concerns, I will address these with my esthetician. I give permission to my esthetician to perform the eyelash lifting procedure we have discussed and will hold her harmless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, or products I am currently ingesting or using topically. I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the esthetician immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. 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. I understand the procedure and accept the risks. I do not hold the esthetician, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure that may be affected by the treatment performed today.

  • Date Signed
     - -

  • Client Policies

  • Estie Co. will now require 24 hours notice for rescheduled and canceled appointments.
    There will be a 50% charge of service booked for last-minute (within 24 hours) cancellations or reschedules.

    90% of the service booked will be charged for no-call/no-shows. This will need to be paid before you are allowed to book another appointment. Refusal to pay will result in a ban from my schedule.

    If you are running 15+ minutes late for your appointment, there will be a 50% charge of the service booked and the appointment will need to be rescheduled.

    Sickness: Please, please do not come to your appointment if you are feeling sick AT ALL. Reschedule your appointment for a later date. This keeps everyone safe and allows Jules to continue working. There will be no exceptions for this, if you are sick, you will be sent home and charged 90% of the service.

    You can easily reschedule your appointment by going to the link that is sent to your email when you book. We know that last-minute things pop up so please make sure you reach out when canceling/rescheduling.
     
    By signing below, I am agreeing to the policies stated above and agree to pay any penalties that may be charged by Estie Co. LLC in accordance to these policies.

  • Illness Information & Liability Waiver

  • 1. Have you had a fever in the last 24 hours of 100°F or above?
  • 2. Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?
  • 3. Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus type symptoms?

  • COVID-19 is a highly contagious virus that spreads from person to person. In addition to long-held and explicit sanitation measures this business has always adhered to, new preventative measures have been put in place to further reduce the spread of this novel coronavirus. However, these best practices still offer no guarantee regarding your potential risk of being infected. 


    Consent for Treatment 

    I understand that, because esthetics involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any claims related thereto. I give my consent to receive treatment from this practitioner.

  • Date
     - -
  • Should be Empty: