CONSENT FORM FOR LASH LIFT
Name
FIRST NAME
LAST NAME
Address
ADDRESS
Street Address Line 2
CITY/STATE
State / Province
Postal / Zip Code
CELL PHONE
Format: (000) 000-0000.
EMAIL
example@example.com
BIRTHDAY
REFERRAL
Have you experienced any of the following? Please answer the following questions:
Rows
YES
NO
Do you wear contact lens?
Are you currently taking any medications? If yes, please list
Have you had a lash lift procedure done:
Are you currently pregnant?
Are you currently breastfeeding?
Have you had any recent surgery to the eye area?
Do you have any allergies?
Demerits
Dry eye
Conjunctivitis/ Eye Mites
Blepharitis
Permanent Makeup
Hormone Imbalance
Seasonal Allergies
Cataracts
Lasik Surgery
Eczema
Retinoids
Blepharoplasty
Glaucoma
Are you currently taking any medications? If yes, please list
By signing below, I acknowledge that I have read the above information and give my consent forLash Lift Procedure. This consent form Is valid for all future procedure I will alert the staff If thereare any future changes to my medical history.
Submit
Submit
Should be Empty: