Informed Consent: Eyelash Lift
Name
Address
Address
Street Address Line 2
City
State
(Zip
Phone
Email Address
example@example.com
Yes/No
List any allergies you have:
Have you had an eyelash lift in the past? Yes/No If yes, when?
Have you ever used hair color/eyelash tint? Yes/No
Have you ever had an allergic reaction to hair color/eyelash tint? Yes/No
Do you wear contact lenses? Yes/No
Do you wear contact lenses? Yes/No
Are you currently using eye drops of any kind, prescription or over-the-counter? Yes/No
Do you have a history of dry eyes or Sjorgen's Syndrome?
Do you have a history of recurrent eye or tear duct infections? Yes/No
Do you have a history of dry eyes or Sjorgen's Syndrome? Yes/No
List any allegries you have:
List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process and retention of this eyelash lift:
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, that 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 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 having my eyes closed and covered for the entire duration of the procedure.
I have read the above information. If have any concerns, I will address these with my esthetician/ technician. I give permission to my esthetician/technician to perform the eyelash lifting procedure we have discussed and will hold him/her and his/her staff 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/technician 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/technician immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that have read, and fully understand, the above paragraphs and that 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/technician, 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. By signing below, I verify that I have read and understand the above statements and agree to them. Client Name (Printed)Client Name (Signature) Date:
Client Name (Signature)
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Esthetician/Technician
Date
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