Lash Lift & Tint Intake Form

Lash Lift & Tint Client Intake Form
Name*
Date of Birth*

MonthDayYear
Date
Address*
City*
State*
Zip Code*
Phone*
Email*
example@example.com
Occupation*
Emergency Contact Name*
Phone*
Would you like to be added to our email list for specials and discounts?

YesNo
How did you hear about us*
Have you ever had your brows or lashes tinted?*

YesNo
If yes, have you ever had an adverse reaction?*

YesNo
If yes to reaction, please explain
Have you used hair color before?*

YesNo
Have you ever had an allergic reaction to hair color?*

YesNo
If yes to reaction, please explain
Do you use Mascara on your eyelashes?*

YesNo
Do you use a lash serum on your eyelashes?*

YesNo
Do you wear contact lenses?*

YesNo
Do you have frequent eye irritation, itching, or watery eyes?*

YesNo
Are you or could you be pregnant?*

YesNo
Do you have, or are you being treated for any kind of eye injury?*

YesNo
If yes please explain
Do you have any allergies?*

YesNo
If yes please explain
Are you currently taking any medications or supplements?*

YesNo
If yes please explain
Do you have any of the following conditions? (Please check all that apply)

AlopeciaConjunctivitisEczemaPsoriasis Around the EyesSensitive EyesCancerDiabetesGlaucomaThyroid DiseaseCataractDry EyesLupusRecent Eye InfectionOther
Please list any illness or condition you are currently being treated by a physician for
By signing below, I agree to the following: I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition (s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liability toward my technician and the salon for any injury or damages incurred due to any misrepresentation of my health.
Signature

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Date

MonthDayYear
Date
Lash Lift & Tint Consent Form
Although every precaution will be taken to ensure my safety and wellbeing before, during, and after the tinting process, I am aware of the following information and possible risks. Please check that you understand and sign below:
I understand that tinting/perming lashes has some inherent risk of irritation to the orbital eye area including the eye itself and could result in stinging or burning blurry vision and potentially blindness should the tint enter into the eye*

Yes
I understand that if the tinting agent, developer, or mixture of both accidentally comes into contact with my eye, my eye will be flushed with water and medical attention may be required*

Yes
I understand that there could be some irritation, itching, or burning may occur to the skin which comes in contact with the tinting agent.*

Yes
I understand that there may be some residual dark staining left on the skin following the tinting process of my lashes This will fade and go away within a short time*

Yes
I understand that while every attempt will be made to provide me with my chosen color everyones hair absorbs color differently and my final results may not be the color I initially wanted.*

Yes
I understand that over the course of several weeks the tint will gradually lighten and fade Retinting will be required to keep the new color fresh Most clients need to retint every 3-4 weeks.*

Yes
I understand that it is imperative that I disclose all of the information requested on the Client Intake Form*

Yes
I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications*

Yes
I understand that additional conditions could occur or be discovered during the procedure which could affectmy ability to tolerate the procedure*

Yes
I consent to before and after photographs for the purpose of documentation potential advertising and promotional purposes.*

Yes
I agree that if I experience any ill effects with my lashes that I will contact the technician that performed this procedure.*

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

Yes
I understand and agree to the aftercare instructions provided by the technician I realize and accept the consequences of failure to adhere to these instructions.*

Yes
I currently use contact lenses (which I may be asked to remove during the procedure) | currently use products such as oil- containing sunscreen or moisturizers around my eyes I currently use eye drops

I have allergies or sensitivities I have a history of recurrent eye or tear

I have a history of dry eyes or Sjogren's Syndrome | have a recent history of Chemotherapy

By signing below, I agree to the following: I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. I agree I will assume the risk and full responsibility for any and all injuries, losses, side effects, or damages that might occur to me while I am undergoing this procedure. I do not hold the esthetician, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this skincare procedure, which may be affected by the treatment performed today.
I am informing the technician of the following conditions that apply to me check all that apply

I currently use contact lenses ( Which I may be asked to remove during the procedure)I have allergies or sensitivitiesI have a history of recurrent eye or tear duct infectionsI currently use products such as oil-containing sunscreen or moisturizers around my eyesI have a history of dry eyes or Sjogren's SyndromeI currently use eye dropsI have a recent history of Chempothemotherapy
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Lash Lift & Tint Client Intake Form

Lash Lift & Tint Consent Form