Lash Lift & Tint Consent Form

Name *

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number *

Area CodePhone Number

Email *

example@example.com

I consent to having my eyes closed and covered for the duration of the 45-60 minute procedure *

YesNo

I am informing my technician of the following conditions by marking with a check

Current use of contact lenses which I agree to remove before treatmentCurrent use of anything such as oil-containing sunscreen or moisturizers around the eyesCurrent use of eyedrops of any kind, prescription or over-the-counterCurrent allergies or sensitivities to instruments, fumes, tapes, cleaners, eye gel pads, adhesives, and removers that could cause my eyes to water and blink in excessHistory of recurrent eye or tear duct infectionsHistory of dry eyes or sjorgen’s syndromeOther medical conditions which would prohibit and compromise the process and retention of these treatments

I agree to have an eyelash lift (perm) and/or eyelash tint applied to my natural eyelashes. By signing this agreement, I consent to the procedure of an eyelash perm, and or eyelash tint.
I understand there are risks associated with having an eyelash perm and/or eyelash/eyebrow tint. I further understand that as part of the procedure, eye/skin 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/skin I will contact the service provider 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/skin 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 to the following Post- Lash Lift/Tint:

No water can come in contact with the eye area for 24 hours after the application
Avoid using oil-containing sunscreens, moisturizers, and cleansers on the lashes

Acknowledgment and Waiver

I am over 18 years of age and consent to the agreement and to treatment or have a guardian that consents to this service. This agreement will remain in effect for this procedure and all future lash services conducted. I understand that this consent agreement is legal and binding. I have read and fully understand all information in this agreement. I release the service provider from all liability associated with these treatments, which are 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 the 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.

I understand the above information:

I agree

Reservation & Cancellation Policy for all current and future appointments: a valid credit card is required for all appointments. Please do not forget to confirm your appointment when you receive your reminder from Square. In the event of cancellations received less than 48 hours prior to appointment a cancellation fee equal to the reserved service booking will incur. No Shows will be charged 100%

I understand the reservation and cancellation policies at White Rose Beauty Studio and consent to my credit card on file being charged if I fail to give a 48 hour notice for appointments scheduled.

Signature by client or guardian of client: