Lash & Brow Tint and Lamination Consent Form
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Have you ever used hair color/eyelash tint?
*
Yes
No
Have you ever had an allergic reaction to hair color/eyelash tint?
*
Yes
No
Do you wear contact lenses?
*
Yes
No
Are you currently using eye drops of any kind, prescription or over-the-counter?
*
Yes
No
Do you have a history of recurrent eye or tear duct infections?
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Yes
No
Do you have a history of dry eyes or Sjorgen’s Syndrome?
*
Yes
No
Please list any allergies you have:
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Please list any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process and retention of this eyelash or brow lift:
*
Although every precaution will be taken to ensure your safety and well-being before, during, and after your eyelash or brow lift, please be aware of the following information and possible risks. Please initial:
I understand that there are risks associated with having an eyelash lift.
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I understand that as part of the eyelash lift procedure, eye irritation, eye pain, eye itching, discomfort, and in rare cases, eye infection or blurriness could occur.
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I agree that if I experience any of these conditions with my eyelashes or eyes or brows, that I will contact my technician; if I choose to consult a physician, it will be at my own expense.
*
I understand that an eyelash/brow lift will lift my natural eyelashes/brows. Depending on my natural eyelash/brow length and strength, results may vary.
*
I understand and agree to the care instructions provided by my esthetician for the use and care of my eyelashes or brows after the eyelash or brow lift. I realize and accept that the consequences of failure to adhere to these instructions may cause the eyelashes or brows to not stay as lifted as long as originally told.
*
I understand and consent to having my eyes closed and covered for the entire duration of the procedure.
*
I consent to "before" and "after" photographs for the purpose of documentation, potential advertising and promotional purposes.
*
Yes
No
I agree to the following lash & brow lift and tint care and maintenance instructions: No water can come in contact with the eye area for 24 hours after the application.This agreement will remain in effect for this procedure and all future procedures conducted by my esthetician. I have read the above information. If I have any concerns, I will address these with my esthetician. I give permission to my esthetician to perform the eyelash lifting procedure we have discussed and will hold Grace Skin Studio and her harmless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, or products I am currently ingesting or using topically. I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the esthetician immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the esthetician or Grace Skin Studio responsible for any of my conditions that were present, but not disclosed at the time of this procedure that may be affected by the treatment performed today. By signing below, I verify that I have read and understand the above statements and agree to them.
*
Submit
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