Lash Lift & Tint Consent

1

Name* This field is required.

First Name

Last Name

2

Phone Number* This field is required.

Please enter a valid phone number.

3

Have you had a lash lift before?* This field is required.

Yes

No

4

I wear contacts* This field is required.

Yes

No

5

I am informing Skin by icy of any of the following contraindicated conditions.* This field is required.

Allergies to adhesive tape, fumes or eye remover

Dry Eye Syndrome

Sjorgen's Syndrome

Currently having Chemotherapy

Ocular Rosacea

Pregnant

None

6

I consent to having my eyes closed and covered for the duration of the 45-60 minute procedure.* This field is required.

Yes

No

7

I, understand , accept the following statements:* This field is required.

I agree to have an eyelash lift (perm) and/or eyelash tint applied to my natural eyelashes and/or retouched. By signing this agreement, I consent to the procedure of an eyelash perm or eyelash tint by my technician.

I understand there are risks associated with having an eyelash perm 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.

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 or require a physician’s follow-up care.

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

I agree as post-lash lift that no water can come in contact with the eye area for 24 hours after the application and I avoid using oil containing sunscreens, moisturizers and cleansers of on lashes.

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. This agreement will remain in effect for this procedure and all future procedures conducted by my technician. I understand that this consent agreement is legal and binding. I have read and fully understand all information in this agreement. I release my technician Skin by Icy from all liability associated with this procedure, 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. There are no guarantees for length of time the lashes will stay permed. 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 eyelash lift such as water and moisture contact, weather conditions, and activities involving exposure to high temperatures. By signing below, I verify that I have read and understand the above statements and agree to them.

8

Signature* This field is required.

9

Date* This field is required.

Date