Lash Lift and Lash/Brow Tint Consent Form

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Do you wear contacts? Contacts must be removed prior to every service.

Please list any medications, over the counter or prescription you are currently using

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

Have you ever had your lashes or brows tinted?

If you had an adverse reaction to a previous tinting, please explain

I consent to having my eyes closed and covered for the duration of the 25-90 minute procedure.

Initial

I grant permission to use my before and after photos/videos for marketing or examples of my technician's work.

I understand that in order to get the tinting procedure that a consultation/patch test is required and failure to receive a patch test can result in an allergic reaction that my esthetician is not liable for.

Initial

Although every precaution will be made to ensure your safety and well-being before, during and after your tinting application, please be aware of the possible risks below:

I understand that tinting lashes or brows has some inherent risk of irritation to the orbital eye including the eye itself, and could result in stinging or burning, blurry vision and potentially should the tint enter the eye.

Initial

I understand that if the tinting agent, developer, or mixture of both accidentally come into with my eye, my eye will be flushed with water and medical attention may be required.

Initial

I understand that some irritation, itching, burning, tingling, or slight redness may occur to the skin which comes into with the tinting agent. I agree that if I experience any of these medical conditions with my lashes or brows that I will contact my technician and consult a physician at my own expense.

Inital

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/brows or require a physicians follow-up care.

Initial

I understand that there may be some residual dark staining left on the skin following the tinting of either my lashes, brows, or both. This will fade and go away within a short time.

Initial

I understand that while every attempt will be made to provide me with my chosen color, hair absorbs color differently and my final results may not be the color I initially wanted.

Initial

I understand and agree to the care instructions provided by my technician for the use and care of my permed and/or tinted eyelashes/eyebrows. I realize and accept consequences of failure to adhere to these instructions which may cause the eyelashes not to stay permed as long.

Initial

I understand that over the course of several weeks, the tint will gradually lighten and fade. Retouch will be required to keep the color fresh. Usually every 3-4 weeks.

Initial

I agree to the following aftercare:

No water can come in contact with the eye or brow area for 24 hours after application.
Avoid makeup such as mascara, eyeliner or brow pencil for first 24 hours.
Avoid using oil-containing sunscreen, moisturizers and cleansers on lashes for first 24 hours.

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.

I have read the above information. If I have concerns, I will address them with my esthetician. I give permission to my esthetician to perform the perming or tinting procedure we have discussed, and will hold my esthetician 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 that 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. This agreement will remain ineffect for this procedure and all future procedures conducted by my esthetician. Should anything change, I agree to inform my esthetician of the changes. 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 responsible for any of my conditions that were present, but not disclosed at the time of the skin care procedure, which may be affected by the treatment performed.

Client Name (Signature)

Date