Eyebrow & Eyelash Service Consent Form
Thank you for choosing Skin A Peel Beauty Lounge please complete the following form below prior to service.
Name
*
First Name
Last Name
Phone Number
*
Email
*
example@example.com
Please select the following service(s) you will be receiving
*
Eyebrow Tint
Eyebrow Lamination
Eyelash Tint
Eyelash Lift
Health History | Please check any of the following that applies to you
*
Allergy to adhesives band aid or medical tape
Recent history of Chemotherapy
Seasonal allergies
Current use of eyedrops
Eye illness or injury
Blepharitis (inflamed eyelids)
Permanent eye-makeup
Eye lift
Drugs that can cause temporary hair loss
Major surgery within last 120 days
Current use of contact lens
Please agree to the terms and conditions
*
I agree to have the following service(s) checked above .
I understand that are risks associated with eyebrow and/or eyelash services done that may include but are not limited to eye irritation, eye pain, itching discomfort, and in rare cases eye infection or blurriness could occur.
I agree that if I experience any conditions listed above I will contact my technician and consult a physician at my own expense.
I understand and consent that some eyebrow/eyelash procedures may require having my eyes closed and covered for the duration of the 45-60 minute procedure
I release my technician 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
I understand the length of results may vary and the importance of following after care instructions provided by technician. Failure to adhere to aftercare instruction may effect results of procedure.
I consent to take photographs during my treatment
Date
*
-
Month
-
Day
Year
Date
Client Signature
*
Technician Name
First Name
Last Name
Technician Signature
Submit
Submit
Should be Empty: