Eyelash Lift/Eyelash Tint Consent Form

Client's Name*

First NameLast Name

Gender*

MaleFemale

Date of Birth*

Date

Phone Number*

Email Address*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How did you hear about us?*

Please check all that apply.*

Are you taking any contraceptive pills?*

YesNo

Are you breastfeeding?*

YesNo

Have you ever had an eyelash lift in the past?*

YesNo

If you have had an eyelash lift in the past, WHEN?

Have you ever used hair color/eyelash tint?*

YesNo

Have you ever had an allergic reaction to hair color/eyelash tint?*

YesNo

Are you wearing any contact lenses?*

YesNo

Are you currently using eye drops of any kind, prescription or over-the-counter?*

YesNo

Do you have a history of recurrent eye or tear duct infections?*

YesNo

Do you have a history of dry eyes or Sjorgren's Syndrome?*

YesNo

List any allergies (if any): *

List any illnesses, medical conditions, or medical treatments (if any) you have recently received that would prohibit or compromise the process and retention of this eyelash lift and/or tinting service: *

Although every precaution will be taken to ensure your safety and well-being before, during and after your eyelash lift and/or tinting service, please be aware of the following information and possible risks.

Please initial the following:

I understand that there are risks associated with having an eyelash lift or eyelash tinting service.*

I understand that as part of the eyelash lift procedure or eyelash tinting service, eye 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 conditions with my eyelashes or eyes, that I will contact my technician. If I choose to consult a physician, it will be at my own expense.*

I understand that the instruments, tapes, cleaners, eye gel pads, adhesives, and/or removers may irritate my eyes or require a physician's follow-up care, even though my technician utilized correct procedures/techniques and has followed proper safety protocols.*

I understand that an eyelash lift will lift my natural eyelashes. Depending on my natural eyelash length and strength, results may vary.*

I understand and agree to the care instructions provided by my technician for the use and care my eyelashes after the eyelash lift. I realize and accept that the consequences of failure to adhere to these instructions may cause eyelashes to not stay as lifted for as long as originally specified by technician.*

I understand and consent to having my eyes closed and covered for the entire duration of the procedure. *

I agree to the following:

Eyelash lift and/or eyelash tint care and maintenance instructions: No water can come in contact with the eye area for 24 hours after the applications.

This agreement will remain in effect for this procedure and all future procedures conducted by my technician.

Legal Age Requirement: By booking a service with us, you affirm that you are of legal age, which is at least 18 years old. It is a requirement that all clients who seek to receive these services meet this age criterion.

I have read the above information. If I have any concerns, I will address these with my esthetician/technician.

I give permission to my esthetician/technician to perform the eyelash lifting and/or eyelash tinting procedure we have discussed and will hold him/her and his/her staff 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/technician 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/technician 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/technician 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.

I request and consent to these procedures being carried out today without undergoing a sensitivity patch test. The sensitivity test, which if conducted may indicate my sensitivity / allergy to the products.

I understand the contents of this form and take full responsibility for my actions, thus absolving all other parties of their responsibilities, if any, associated with the supply of the products and services(s).

APPOINTMENTS

Retainer Payment: A 50% non-refundable retainer payment is required to secure all service appointments. This amount is credited towards your service on the day of your appointment.

Please remove all makeup PRIOR to your appointment.

Please arrive 10-15 minutes PRIOR to the start of your appointment to complete all consent forms. These forms are also available online and may be completed PRIOR to your appointment. (Please note that in the event your consent forms ARE NOT completed PRIOR to the start of your appointment, this may result in a shortened appointment time.

RESCHEDULING & APPOINTMENT CANCELLATIONS

Rescheduling: If you reschedule your appointment with less than 24 hours' notice, a new retainer will be required to secure the new appointment time. To cancel or reschedule, please contact us directly by email at info@blushartistrytx.com or by phone at (832)850-6138.

Cancellation Timeframe: If you need to reschedule or cancel your appointment, please do so at least 24 hours in advance of your appointment start time.

Late Cancellations: Cancellations made less than 24 hours from the scheduled appointment start time will result in the forfeiture of the 50% retainer payment. (This policy is in place because short-notice cancellations provide insufficient time to fill the vacated slot, thereby impacting our staff and other clients.)

LATE ARRIVAL

Notification of Late Arrival: If you anticipate being late, we kindly ask that you inform us as soon as possible. This allows us to adjust our schedule and advise you on the best course of action.

Grace Period: We understand that minor and unexpected delays can happen. A grace period of 15 minutes is allowed for all appointments. During this time, we will hold your appointment slot open for you, however, please note that the original appointment time may be shortened.

Arrival Beyond 15 Minutes: If you arrive more than 15 minutes after your scheduled appointment start time, your appointment will be considered canceled. In such cases, the following terms apply:
a. Forfeiture of Retainer: Your initial 50% retainer payment will be forfeited as it compensates our staff for their reserved time and the lost opportunity to serve other clients.
b. Rescheduling Your Appointment: To reschedule your missed appointment, a new 50% retainer payment will be required. This ensures the commitment to your new appointment time and availability of our services.
c. Appointment Shortening: Depending on our booking schedule, we may offer to shorten your service instead of canceling it if you arrive within the grace period. However, this is subject to availability and cannot be guaranteed.

NO SHOWS

No-Shows: Clients who fail to show up for their scheduled appointment without any prior notification will also forfeit the retainer payment. Repeated no-shows may result in refusal of future service.

Communication: To cancel or reschedule, please contact us directly by email at info@blushartistrytx.com or by phone at (832)850-6138.

I understand that my data will be strictly confidential. This business establishment does not sell, share, or resell information. I confirm that all information in this form is true and accurate. I confirm that if I hold some important information and complications happened, the business establishment will not be liable. I release this business establishment and hold harmless against any claims, expenses, damages, and liabilities.

Name*

First NameLast Name

Client Signature

Date Signed

Date

Professional Use Only/ Notes Section

Eyelash Lift/Eyelash Tint Consent Form

Policies

Terms & Conditions