Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Age
*
Do you have any open skin lesions on the face?
*
Yes
No
Do you wear contacts?
*
Yes
No
Have you received an eyelash lift in the last 8 weeks?
*
Yes
No
Have you received an eyebrow lamination in the last 8 weeks?
Yes
No
I am informing my technician of any of the following contraindicated conditions for my lash lift.
I am pregnant or breastfeeding
Dry eye syndrome
Alopecia
Conjunctivitis
Trichotillomania
Hyper thyroid
Ocular rosacea
I am informing my technician of any of the following contraindicated conditions for my eyebrow lamination.
Dermatitis
Sensitive skin
Do you have any allergies? If so, please list.
Please note that eyelash lifts and eyebrow laminations can have certain side effects such as irritation, redness, rash, etc.
I have read the above information and have given an accurate account of the questions.
I give permission to Rianna's Aesthetic Studio to perform the eyelash lift and eyebrow lamination we have discussed and will hold her harmless from any liability that may result from this treatment.
I agree to adhere to all safety post care including: no water or makeup on the affected area for the first 24 hours.
I understand that Rianna's Aesthetic Studio will take every precaution to minimize or eliminate negative reactions.
I understand there are risks associated with having an eyelash lift 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.
Signature of Client
Date:
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