Eyelash Lift & Tint Treatment Consent Form

Informed Consent for: Lash Lift & Lash Tint

By LashwithG
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
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Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please read the following
You must be over 18 to consent to services. You must be over 16 to receive services. Under 18 requires parental signature
Have you ever used hair color before?
Have you ever had your lashes lifted or tinted?
I agree to have eyelash lift and/or eyelash tint applied to my natural eyelashes and/or a retouch and I do understand that I may not be a candidate for a lash lift if I have damaged lashes or lashes with gaps or have extremely short natural lashes.
We suggest checking with your doctor prior to having a lash lift and/or lash tint if you: are pregnant, nursing, have chronic dry eye, conjunctivitis, eye infections, trichotillomania, have recently undergone chemotherapy, or have recently had Lasik or blepharoplasty surgery.
I understand that there are risks associated with having any of these procedures. I further understand that as part of the procedure eye irritation, eye pain, eye itching, discomfort, and in rare cases, eye blurriness or infection can occur. I agree that if I experiences any of these conditions with my lashes, I will contact my technician and consult a physician at my own expense.
I understand that though my technician uses proper technique, instruments, adhesive, tape, cleansers, eye gel pads, and removers, my eyes may become temporarily irritated or in rare cases, require a physician’s care. I release my technician from all liability associated with the procedure(s), 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.
I understand and agree to the care instructions provided by my technician for the use and care of my eyelash lash lift and/or lash tint. I understand and accept the consequences of failure to adhere to these instructions, and that it may causes the lashes to not perform at optimal level. *** Please check all boxes off to confirm you have read them and understand.
I understand that these procedures are semi-permanent and that my natural lashes will continue to grow and fall out normally, making touch-up appointments necessary to maintain the original look of the procedure(s). Most clients require a appointment every 3-4 weeks. There are no guarantees for the length of time your procedure will last. Please follow the instructions above for best results.
I understand that additional conditions could occur or be discovered during the procedure. I agree that if at any time, I am uncomfortable with the lash lift and tint treatment, I will inform the technician and she will gladly rectify the problem, including ending the session.
I understand and consent to having my eyes closed for the duration of approximately 60 minute procedure and that it is my responsibility to keep them closed and remain still during this time. Procedure times vary. *
I consent to Before and After photographs for purpose of documentation purposes.
I consent to you publishing and reproducing photographs of me, my face, and/or my eye area, both before and/or after the procedure
I understand that it is imperative that I disclose all information requested in the provided Aesthetics Confidential Client History.
Do you currently use contact lenses and agree to remove them during application
Current use of eyedrops of any kind
Current allergies to anything that could cause my eyes to water or blink to excess
History of recurrent eye or tear duct infections
History of dry eyes or Sjogren’s Syndrome
Other conditions affecting the procedure
I confirm that I have NOT been in close contact with someone who has tested positive for the novel coronavirus or someone who has been required to self-isolate within the last 10 days.
I understand the cancellation policy as follows: *** Please check all boxes off to confirm you have read them and understand.*
If you have any questions please feel free to leave them here to discuss upon arrival or you can call me to discuss prior to the visit.
By Signing below, I verify the information I have provided on this consent form is truthful and accurate. I knowingly and willingly consent to having treatment.
This agreement will remain in effect for all lash lift and/or tinting procedures performed. I read English and understand that this agreement is legal and binding. I will not hold LashwithG or any of its service providers liable for any damages on this day or any day forward. I have read and understand all information in this agreement. I am over 18 years of age and consent to this agreement and to the services rendered.
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Informed Consent for: Lash Lift & Lash Tint

Please read the following

I understand that it is imperative that I disclose all information requested in the provided Aesthetics Confidential Client History.