• Lash Lift Form

  • Format: (000) 000-0000.
  • Do you have any allergies? If yes specify other*
  • Do you wear glasses?
  • History, Conditions, + Allergies*
  • Do you wear contact lenses?
  • Do you use any medicated eye drops?*
  • Do you have an allergy to adhesive Band-Aids Or medical tape?*
  • Do you have an allergy to surgical glue or nail glue?*
  • Do you have seasonal allergies?*
  • Do you have an allergy to glycerin?*
  • Do you have permanent eye make up?
  • Have you had an eye lift?*
  • Are you taking Any medication that can cause temporary hair loss?*
  • Have you had major surgery within the last 120 days?*
  • Are you currently diagnosed with cancer and/or receiving or have received chemotherapy in the last six months?*

  • This form is designed to inform guests about the Lash Lift procedure, its potential risks, and responsibilities. By signing this form, the guest acknowledges and agrees to the terms outlined below.

    AFTERCARE INSTRUCTIONS

    Maintain healthy lashes by keeping healthy hydrated lashes!

    • Using supplied aftercare kit I give beautiful brows and lashes step 3 hydrating serum.
      3-4.5 week Refresh appointment is a check in on lash health, consult, lash hydration treatment and re-tinting if desired! 
      if you run out you can bring your empty container to a refresh or lift and tint appointment for a refill. OR after the first two weeks a nourishing oil can be considered and applied to lashes. This is recommended due to drying from treatment. Coconut oil, jojoba oil, warm castor oil on a small spoolie applied to tips of lashes. Discretion is advised if oil is used instead of provided aftercare. 

      You should avoid excess water cleanser, steam, and heat for minimum 6 hours after procedure is complete. You should avoid oil based products around the eye area 24 hours.
    • Avoid using mascara, lash serums, or waterproof makeup for at least 24 hours post-treatment.
    • Avoid curling your eyelashes for minimum 6 weeks.
    • Avoid sleeping on your face and rubbing eyes for 48-72 hours. Avoid rubbing your eyes for 48-72 hours.

    Inform the technician of any allergies, eye conditions, or sensitivities prior to the procedure. Follow aftercare instructions to maintain optimal results.

    RISKS & POTENTIAL SIDE EFFECTS

    • Temporary redness, irritation, or itching may occur.
    • An allergic reaction is rare but possible. A patch test is recommended at least 24-48 hours before the procedure.

    Lashes may become dry or brittle if aftercare is not followed correctly.

     

  •  

    I agree to have and eyelash lift and/or eyelash tint applied to my natural eyelashes
    and/or eyelash refresh.
    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 agree that if any time I am uncomfortable with the lash lift and tint treatment. I will inform the esthetician and they will promptly rectify the problem including ending the session if necessary. I understand and consent to having my eyes closed and covered for the duration of the procedure.

    I understand and agree to the aftercare instructions provided by my technician for the use and care of my 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. 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 guests prefer a lash refresh around the 3-4.5 week mark and eyelash lift and/or tint would be every 6-8 weeks.

    I understand that additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure and hence, the outcome.

    I understand that it is imperative that I disclose all information requested in the provided in the history section. If you dont see something listed that should be considered please leave it in the notes section.

    I consent to give, Face Space By Alyssa LLC or certified technician, permission to take Before and After photographs of me to publish and reproduce of my face and or my eye area, for advertising, marketing, promotional purposes, and other purposes.

  • Consent & liability

    I understand there are risks associated with having a lash lift and/or tint, I further understand that as part of the procedure I irritation, eye pain, I itching, discomfort, and in rare cases allergic reaction, infection, or blurriness could occur. You may have a patch test at least 24 hours before your appointment if you wish. I agree that if any time I am uncomfortable with the lash lift and tint treatment. I will inform the esthetician and she will gladly rectify the problem including ending the session.

    I understand and consent to having my eyes closed and covered for the duration of the procedure.

    You must prepare your eye area prior to your arrival eyelashes should be clean, dry, and free of makeup, mascara, and oil residue. If you attend your appointment without proper preparation, The Skin Distillery Esthetics, cannot guarantee lasting or satisfactory results. Please let us know if you have any mascara residue on your lashes prior to procedure. If you attend your appointment with unclean lashes you may be subject to additional of charge for proper cleaning.

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

    for optimum results avoid direct heat, steam, mascara, and other skin care products around your eye area for at least 24 hours after the application.

    There are no guarantees for the length of time your lash lift and or tint will last. I understand the aftercare instructions and will do my part to maintain my eyelashes. I understand that there are many factors that may affect the life of the lash lift and or tint such as water and moisture contact, weather conditions, and activities involving exposure to high temperatures.

    We suggest checking with your doctor prior to having a lash lift and/or tint if you were pregnant, nursing, have chronic dry eye, conjunctivitis, Eye infections, trichotillomania, have recently undergone chemotherapy, or have recently had Lasik or Blepharoplasty surgery.

    A lash lift and Tint may not be for you if you: have damaged Lashes or Lashes with gaps or have extremely short natural lashes. 

    I acknowledge that the results of lash lift and/or lash tint do vary and that no guarantees are specific results are offered or implied. I take some responsibility for any reaction I may have, staining of clothing and or personal belongings. Agreed to hold The Skin Distillery Esthetics and all authorized representatives harmless from any liability involved in the lash lift and or tint process. The Skin Distillery Esthetics and their staff have explain this procedure to me and all my questions, if any, were answered.

    I have reviewed and completely understand all the information included in this form I give, The Skin Distillery Esthetics, permission to take publish and reproduce photographs of me in my face and or my eye area both before and or after the procedure for advertising and other purposes.

     

  • I request and consent to these procedures being carried out today without undergoing a sensitivity patch test. The sensitivity test, which if conducted may indicate my sensitivity / allergy to the products. I understand the contents of this form and take full responsibility for my actions, thus absolving all other parties of
    their responsibilities, if any, associated with the supply of the products and services(s).

    By signing this agreement, I confirm that I have read, understood, and agreed to all the terms stated above

  • Date*
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