Lash Lift & Tint

Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How did you hear about Allora Beauty Bar?

Is this the first time you have had a lash lift & tint?

YesNoJust LiftJust Tint

Do you habitually rub, pull or pick your lashes for any reason?

YesNo

Do you have, or are you being treated for any eye illness or injury?*

YesNo

If yes, please explain.

Are you currently taking any medication?

Do you have allergies?

Are you over the age of 18?*

YesNo

• I understand there are risks associated with having an eyelash perm and/or eyelash tint.

• I understand that it is my responsibility to keep my eyes closed and be still during the entire procedure, until my eyelashes technician addresses me to open my eyes.

• I understand that as part of the procedure, eye irritation, 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.

• There are no guarantees for length of time the lashes will stay permed. I understand the aftercare instructions and will do my part tomaintain my eyelashes. I understand that there are many factors that may afect the life of the eyelash lift such as water and moisture contact, weather conditions, and activities involving exposure to high temperatures.

• 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 agree that by reading and signing this consent form, I release Allora Beauty Bar from any claims or damages of any nature.

• I agree that I read and full understand this entire consent form.

By signing this agreement, I acknowledge that I have been given the full opportunity to ask any and all questions which I might have about the eyelash extensions procedure and that all of my questions have been answered to my full satisfaction.

Signature*

Date*

Date

Allora Beauty Bar

Authorization