Eyelash Extension

Lash Lift & Tint Consent Form
Appointment Date

MonthDayYear
Date of appointment
Hour MinutesAM/PM Option
Client Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Apt. Unit

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Emergency Contact Information

First NameLast Name
Emergency Contact Number
Format: (000) 000-0000.
Have you had a lash lift and/or tint performed before ?
If yes, when? And what service ?
*If you have inflammation, swelling, cuts or abraisons, in the treatment area, the procedure cannot be done.*
Are you pregnant or breastfeeding ?
Do you have any allergies ?
If yes, please list:
Do you have sensitive skin ?
If yes, please explain:
PLEASE CHECK ANY OF THE FOLLOWING THAT MAY APPLY TO YOU:
RELATING TO THE EYE
RELATING TO THE EYELASHES
Other Medical Information
If none, please submit N/A
By checking the following boxes, confirm that you willingly consent to the following terms and conditions:
*I understand that a patch test does not guarantee that an allergic reaction will occur*
*By signing below, I acknowledge that I have read, understood, and consent to the above checklist and the lash lift and/or tint procedure.*
Client Signature
Date

MonthDayYear
Date
Should be Empty:

Lash Lift & Tint Consent Form