Clone of Lash Tint Consent Form

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Full Name* This field is required.
First Name
Last Name
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Your Suburb and Post Code* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
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3
Phone Number* This field is required.
4
E-mail* This field is required.
example@example.com
5
Date of birth* This field is required.
DD/MM/YYYY
6
How did you hear about us?* This field is required.
Google
Social media
Word of mouth
Passing by
Others (Please specify...)
7
How did you hear about us? Others (Please specify...)
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Precautions and Considerations* This field is required.1. Tinting will not add curl, length, or volume of your lashes, but it will darken and intensify their color with semi-permanent, gel-based dye 2. Pregnancy may cause discolouration to the hair once tinted due to hormonal changes I confirm that I have read the precautions and considerations mentioned above and would like to proceed with lash tint service today
YESNO
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Is this the first time you have had lash tint?* This field is required.
YESNO
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If this is not your first time getting lash tint, where and when have you had them applied?
Please type salon name and your last appointment date with them
11
Would you also like your bottom lashes tinted today?We will only be tinting the tips of your bottom lashes and not from the roots. This approach is to minimize any potential irritation that may arise from the tint accidentally coming into contact with your eyes
YESNO
12
Which tint colors do you prefer?* This field is required.
Black
Blue Black
Light Brown
Dark Brown
13
Permission to use pictures* This field is required.I hereby grant my service provider the full right to take, publish and reproduce photographs of me, my face, my eyes and/or lashes, both before and after the procedure, for any advertising, education, or other purposes whatsoever.
YESNO
14
Waiver of liability* This field is required.I agree to having tint applied to my eyelashes. I understand that there are rare risks associated with the procedure such as skin irritation, allergic reaction, and discomfort could occur. I agree that if I experience any of these conditions with my lashes that I will contact professional technician and my GP to seek for immediate medical attention. Whilst proper techniques and procedure will be performed by the lash artist, the instruments, tapes, cleansers, rods, brush, tint, and other product use may irritate my skin/lash. I further agree that I will not hold Mollylash or any of its employees responsible should there be any unfavourable result. I acknowledge and consent to the use of CCTV cameras with microphones in the reception area for the purposes of quality assurance and training. I understand that these recordings are used to enhance service quality and for staff training purposes. Please note that no refund will be given under any circumstances.
YESNO
15
Care and maintenance* This field is required.WITHIN 24 HOURS Keep your eyes dry and avoid contact with water. After 24 hours, you may swim, shower, and exercise as per normal GENERAL CARE 1. You may use mascara on your tinted lashes, but avoid putting it on the first 48 hours 2. Keep your lashes cleaned by properly removing eye make up daily. 3. Use vaseline on the lashes every 2 days to keep it hydrated and healthy. CONFIRMATION I understand that lash tint is temporary, and tint will gradually fade as soon as 24 hours after the procedure is complete. I understand the result varies for everyone and overall lash conditions and after care will ultimately affect the retention of lash tint. I agree to follow the maintenance instruction provided to me by my technician, and that if any follow up care is required due to my own mistake or negligence, or failure to follow these instructions, this will be at my own expense and risk.
YESNO
16
No Known Medical Conditions / Informed Consent* This field is required.I have read and completed the Client Consent Form in its entirety and in truth. I understand that I need to disclose any allergies that I may have to materials or equipment used in lash tint service. I further state that I have no known medical condition that might be aggravated by the procedure or any medical condition that would prevent me from complying with or heeding to instructions or these warnings. This Agreement will remain in effect for this procedure, and all future procedures.
YESNO
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Signature* This field is required.I agree that this Agreement is binding upon me, and my heirs, legal representatives and assigns. I represent that I am at least 18 years of age and that I have the right to enter this agreement.
I am over 18 years old
I am under 18 years old
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Signature of legal guardian* This field is required.I agree that this Agreement is binding upon me, and my heirs, legal representatives and assigns. I am under 18 years of age and I have my parent or legal guardians consent to this agreement.
Clear
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Signature* This field is required.I agree that this Agreement is binding upon me, and my heirs, legal representatives and assigns. I represent that I am at least 18 years of age and that I have the right to enter this agreement
Clear
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You have to agree to our terms and conditions before services can be provided to you
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