Eyelash Lift and Brow Lamination and Tint Form
Name
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First Name
Last Name
Birthday
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Month
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Day
Year
Date
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about us?
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Email
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example@example.com
I am informing my technician of any of the following contraindicated conditions for the lash lift.
Allergies to adhesive tape, fumes or eye remover
Dry Eye Syndrome
Sjorgen's Syndrome
Currently having Chemotherapy
Ocular Rosacea
I am informing my technician of any of the following contraindicated conditions for the brow lamination.
Currently having Chemotherapy
Psoriasis
Eczema
Alopecia
Sun Burn
Ultra Sensitive Skin
Wounds in the treatment area
I consent to having my eyes closed and covered for the duration of the 45-90 minute procedure.
Yes
No
I wear contacts
Yes
No
I, undersigned, accept the following statements:
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I agree to have an eyelash lift, brow lamination and/or eyelash tint applied to my natural eyelashes and/or eyebrows. By signing this agreement, I consent to the procedure of an eyelash perm, brow lamination or eyelash tint by my technician.
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I understand there are risks associated with having an eyelash perm, brow lamination and/or eyelash/brows tint
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I further understand that as part of the procedure, eye irritation, eye pain, eye itching, discomfort, and in rare cases eye infection or blurriness could occur.
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I understand that some mild but normal symptoms may occur with the brow lamination depending on the sensitivity of my skin during the procedure and will subside in 24 hours. These symptoms may include: mild tingling, slight redness due to brushing the hairs, slight warmth in the area.
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I agree that if I experience any of these medical conditions with my lashes that I will contact my technician and consult a physician at my own expense.
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I understand that even though my technician perms the lashes/brows using the proper technique, the instruments, tapes, cleaners, eye gel pads, adhesives, and removers used may irritate my eyes/brows or require a physician’s follow-up care.
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I understand and agree to the care instructions provided by my technician for the use and care of my permed and/or tinted eyelashes/eyebrows. I realize and accept the consequences of failure to adhere to these instructions may cause the eyelashes to not stay permed as long as told.
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I understand that this service is NON REFUNDABLE
I agree to the following Post- Lash Lift:
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No water can come in contact with the lash/brows area for 24 hours after the application.
Avoid makeup such as mascara, eyeliner or brow pencil for the first 24 hours.
Avoid using oil containing sunscreens, moisturizers and cleansers on lashes for the first 24 hours.
Acknowledgement and Waiver
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I am over 18 years of age and consent to the agreement and to treatment or have a parent with me that consents to this service. This agreement will remain in effect for this procedure and all future procedures conducted by my technician. I read English and understand that this consent agreement is legal and binding. I have read and fully understand all information in this agreement. 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. There are no guarantees for length of time the lashes will stay permed. I understand the aftercare instructions and will do my part to maintain my eyelashes. I understand that there are many factors that may affect the life of the eyelash lift such as water and moisture contact, weather conditions, and activities involving exposure to high temperatures. By signing below, I verify that I have read and understand the above statements and agree to them.
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Signature
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Submit
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